A 33 year old male Riker’s inmate presents to the emergency department after corrections officers report that he was observed to have jumped off a chair in his cell, with a bed sheet tied around his neck. Per officers, they were able to cut him down after approximately 1 minute of him being partially suspended. Per our Elmhurst Hospital trauma color protocol, this patient is made a red trauma. The patient is tachycardic (104), hemodynamically stable, and his exam is remarkable for ligature marks circling his anterior neck.
How should you approach the exam of this patient, which specialists should you involve, and how do you decide disposition?
This patient has experienced near hanging.
To review anatomy, the larynx consists of the thyroid cartilage, cricoid cartilage, and hyaline cartilage. The hyaline cartilage becomes ossified with age, so thyroid cartilage fractures are more commonly seen in patients over the age of 40. Fracture occurs via an anterior force by compressing the larynx against the cervical spine.
When examining the airway in trauma, remember LEMON (Look, Evaluate, Mallampati, Obstruction, Neck mobility), and if endotracheal intubation is anticipated, prepare with a ‘double set-up’ (i.e. for cricothyrotomy), and in certain cases, consider awake intubation.
Exam findings concerning for laryngeal fractures include: stridor, hoarseness, surgical emphysema/crepitus, and aphonia.
The Schafer-Fuhrman Classification is used to describe various types of laryngeal injuries, type I-IV.
Type I = minor trauma, no detectable fracture
Treat with humidified O2 and observation
Type II = minor mucosal disruption without exposed cartilage, non-displaced fracture
Treat with tracheostomy + pan-endoscopy (ENT + GI)
Type III = exposed cartilage, displaced fractures, vocal cord immobility
Treat with tracheostomy + stenting + surgical exploration
Type IV = complete laryngotracheal separation
Treat with tracheostomy + surgical exploration + repair
In stable patients, a CT scan of the neck with IV contrast should be obtained for all patients with suspected injury. Also both ENT and GI should be consulted as indicated.
Remember in these patients, to elevate the head of the bed and consider anti-reflux medications and antibiotics.
References:
Borowski David W, Mehrotra P, Tennant D, El Badaway M Reda, Cameron D S, Unusual Presentation of Blunt Laryngeal Injury with Cricotracheal Disruption by Attempted Hanging: A Case Report, American Journal of Otolaryngology, 25 (3): 195-198.
Deshpande S, Laryngotracheal Separation after Attempted Hanging, British Journal of Anesthesia, 81: 612-614, 1998.
Jalisi Scharukh, Zoccoli Mary, Management of Laryngeal Fractures – A 10-Year Experience, Journal of Voice, 25(4) 473-479.
Kaki Abdullah, Crosby Edward T, Lui Anne CP, Airway and Respiratory Management Following Non-Lethal Hanging, Can J Anaesth, 44(4): 445-450.
Kim Jin Pyeong, Cho Sang Jae, Son Hee Young, Park Jung Je, Woo Seung Hoon, Analysis of Clinical Feature and Management of Laryngeal Fracture: Recent 22 Case Review, Yonsei Med J, 53(5): 992-998, 2012.
Pourmand Ali, Shokoohi Hamid, False Passage to the Trachea after Emergency Intubation in a Victim of Near Hanging, Case Reports in Emergency Medicine, 2013: 1-3, 2013.
