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Author: admin, 28.04.2014. Category: Severe Tinnitus Symptoms

Esophageal evaluation usually consists of gastrograffin swallow (less pulmonary sequelae than barium), followed by barium, and then endoscopy. The literature does not provide specific recommendations as to how to evaluate such patients, in part because presentations are so variable, and because discussions of such injuries often lump hangings and manual strangulation together.
Tardieu Spots and result from the rise in venous pressure in response to the strangulation or ligature tightening.
When a patient presents to the ED in significant distress or with signs and symptoms suggesting a specific injury, the management is often obvious. MR of the soft tissues of neck.  In addition, gadolinium-enhanced MR angiography can rapidly image the carotid arteries from the aortic arch to the circle of Willis, making it particularly applicable in the setting of blunt cervical injuries where the level of injury is unknown (2). Carotid doppler ultrasound.  Duplex evaluation is being used increasingly as a screening tool in patients with blunt neck trauma, although angiography remains the gold standard for diagnosing blunt carotid artery injury (2).
There is considerable misunderstanding about the neck injury in hanging, including the notion that radical displaced fractures occur. ZONE IV OF THE NECK?: TEN-YEAR EXPERIENCE WITH PENETRATING TRAUMA TO THE POSTERIOR NECK There were 757 patients with a penetrating neck injury, of which 224 (30%) had a posterior neck wound. Inaba did the largest evaluation of MDCTA to date (The Journal of Trauma and Acute Care Surgery Volume 72(3), March 2012, p 576–584) CTA is accurate, attending physical exam can obviate the need for the CTA in the first place.
It is clear, however, that the severity of traumatic forces that result in significant injury may not be evident on initial examination (1,2,3). A standard evaluation algorithm for the patient who is asymptomatic, however, does not exist.
There are anecdotal reports using helical CT scans to demonstrate blunt carotid artery injuries, but future studies are needed to validate its efficacy.
Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Fracture of cervical vertebrae C2 and C3 (the ?hangman?s fracture?), alleged to occur in judicial hanging, relates to the force applied by dropping the body some distance, against a ligature applied from the side of the neck (30). Cardiac dysrhythmia may be provoked by pressure on the carotid artery nerve ganglion (carotid body reflex) causing cardiac arrest. Pressure on the jugular veins prevents venous blood return from the brain, gradually backing up blood in the brain resulting in unconsciousness, depressed respiration, and asphyxia. The reflex cardiac dysrhythmia can be reproducibly demonstrated in humans, but force must be applied over a very localized and specific anatomic area. If exam shows no signs of vascular or aerodigestive injury at all, imaging may be able to be avoided. Emergency physicians must take seriously any patient who reports a history of recent strangulation injury.
Suggested studies for patients that have been strangled include the following: Soft-tissue neck x-rays should be ordered in nearly all strangulation patients. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries.

The second mechanism (carotid arterial obstruction) is also very uncommon in suicidal hangings, but may be more frequent in homicidal strangulations. Quite a bit of pressure is required to obstruct arterial flow in the carotids, and that amount of force typically would be associated with obvious soft tissue injury locally in the neck.
A common misconception is that there will be fractures or some sort of internal neck injury in people who hang themselves. The third mechanism (jugular venous obstruction) is probably the usual route for death by suicidal hanging. In fact, in suicidal hanging there is scarcely ever any internal evidence of neck injury at all (5,7,10).
Slight pressure fully or at least partially obstructs venous return bilaterally in the internal and external jugular veins, gradually causing passive congestion of blood in the vessels within the brain.
Note that this mechanism is different from surgical ligation or surgical sacrifice of one of the four jugular veins, typical of radical neck surgery.
CONCLUSIONS: Emphasis on clearance of the cervical spine should be a component of the early management of penetrating trauma to the posterior neck. Partially obstructing return in all four veins diminishes oxygen delivery to the brain, eventually resulting in loss of consciousness. External injury, including the dramatic ?rope burns? or ligature abrasion, only occurs after the body has been suspended for several hours after death. Unconsciousness probably doesn?t occur for several minutes, but the overall process is completely painless.
After the body has hanged suspended by the ligature for a few hours, a very dramatic furrow and ligature abrasion will develop post-mortem. In cases of suicidal hanging, eventually the individual becomes unconscious, then the fourth mechanism (laryngeal obstruction) takes over. With the person unconscious, the full weight of the suspended part of the body falls against the ligature, creating enough pressure to restrict air flow through the trachea. Since specific protocols are lacking, it might be illuminating to note how a minimally symptomatic strangulation victim was managed in actual practice at a level 1 trauma center.
In strangulation cases, and some suicidal hangings where the individual is ?saved? before death, there may be a prolonged period of survival with obvious brain damage, followed by death. The patient depicted on the preceding page underwent soft tissue films of the neck, CT imaging of his larynx and MRA to evaluate for possible carotid injury.
This delay is the effect of loss of blood flow to the brain, with partial asphyxiation of the brain.
A decrease in blood flow to the brain will produce a pathologic change called anoxic encephalopathy. One interesting point: Behavioral changes in patients who have been strangled are important to note, but are often dismissed as a psychological in origin given the stress of the attack. Some cells die soon, while others survive for days and eventually succumb to the delayed effect of oxygen deprivation.

Behavioral changes may manifest early as restlessness and combativeness because of temporary anoxia and subsequently resolve. Victims have been reported to die days or even several weeks later because of progressive, irreversible encephalopathy (1).
The nerve cells of the hippocampus and dentate nucleus, and Purkinje cells of the cerebellum, are more susceptible to anoxia than cortical nerve and glial cells. Fatal anoxic encephalopathy results in clinical ?brain death? where the body functions of the heart and internal organs can be maintained by medical life support, but all hope of meaningful recovery is lost. Complications may include persistent vegetative coma, cerebral edema (brain swelling), and herniation of the brain. The amount of force required to compress the jugular veins is less than the force to compress the carotids, and that in turn is less than the force required to constrict the airway. However, absolute values?measured as foot-pounds of force?vary tremendously from one person to the next depending on development of neck musculature, and the surface area for the application of force. If the force were applied over a very narrow surface area?a clothesline ligature as opposed to a broad belt, for example?then much less force would be necessary.
For the same amount of pressure, if you decrease the surface area, or increase the duration of the force, you increase the likelihood that the force will be fatal. Medical resuscitation, and organ procurement procedures, work against the pathologist?s ability to detect fatal homicidal neck injury (12). During resuscitation, an airway tube is placed into the mouth or nose, and inserted into the esophagus or trachea, to establish a path through which air can be forced under pressure to the lungs. The usual airway device is an oral endotracheal tube, but many varieties of hardware exist. The skill of the rescue staff, and the size and rigidity of the victim, dictate how much injury occurs during this intubation procedure. Traumatic intubations result in internal injuries of the deep musculature of the larynx, often completely mimicking the injuries of strangulation.
Ulceration of the larynx may develop from pressure produced by the inflatable cuff on the tube. The mechanical ventilation can produce barotrauma in the lungs, with air dissecting up to the skin of the neck.
In cases where the rescue staff is unable to intubate the patient, they may attempt a surgical cricothyrotomy or tracheostomy procedure to establish an airway. Further, IV needles are sometimes placed into the jugular veins, leaving tracks of hemorrhage that can obscure physical injuries.

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