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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 728-732  

Near hanging: Profile, emergency management, and outcome


1 Department of Emergency, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission03-Oct-2021
Date of Decision30-May-2022
Date of Acceptance31-May-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Dr. Paul Prabhakar Abhilash Kundavaram
Professor, Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_788_21

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  Abstract 


Background: Hanging is a very common mode of deliberate self-harm (DSH) used by patients. The spectrum of the triggers and methods used vary from play to place. Objective: To study the profile and outcome of near hanging. Methods and Materials: A retrospective descriptive study was conducted on patients presenting with near hanging to the Emergency Department (ED) between January 2017 and December 2018. Data were obtained from the triage registry of the ED. Results: During the study period, 1821 presented with DSH with 144 cases of near hanging. The mean age (SD) was 33 (12.9) years and the sex distribution was equal. One-tenth (9.7%) of them had a known psychiatric illness, whereas a quarter of them (22.9%) were under the influence of alcohol at the time of the incident. The most common material used was saree (52.8%). Eight patients were intubated elsewhere and referred to ED, whereas 79% required emergency intubation in ED, with the majority being hypoxic at arrival (84.7%). Of the 144 patients, 58.4% were admitted to the hospital, whereas 20.8% were discharged stable after 24 hours of observation. Among in-patients, the majority (92.7%) were discharged stable, 4.8% left against medical advice, and 2.3% died in the hospital. Conclusions: Hanging as a method of self-harm is used by a tenth of patients who present to the ED with DSH. Saree and rope are the most common materials used for this act. One-fifth of our patients had a bad outcome that was independent of most underlying baseline factors.

Keywords: Deliberate self-harm, emergency department, hanging, near hanging, suicide


How to cite this article:
Ranjan M, Kale Y, Selvan J, Prabhakar AT, Abhilash Kundavaram PP. Near hanging: Profile, emergency management, and outcome. Med J DY Patil Vidyapeeth 2022;15:728-32

How to cite this URL:
Ranjan M, Kale Y, Selvan J, Prabhakar AT, Abhilash Kundavaram PP. Near hanging: Profile, emergency management, and outcome. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Dec 10];15:728-32. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/728/350684




  Introduction Top


Globally, suicides are an important public health issue recognized widely and lead to a million deaths annually.[1] It was observed that for every individual who died of suicide, there were 20 others who attempted one.[1] Hangings in the past were mainly classified into judicial and non-judicial hangings.[2] In non-judicial hangings, the ligature material used is often something that is readily available at hand (saree, dupatta, cable wire, etc.). The sudden drop from a height is almost never achieved, and at times, there is not even a complete suspension of the victim's body weight.[3] However, there may still be compression of the vital structures of the neck because of the body weight. In such cases, the chances of the victim making it alive are much higher and the phenomenon of an unsuccessful attempt where a patient survives the hanging and lands in the hospital is termed “Near Hanging.”[4] In India, hanging is the preferred way of deliberate self-harm (DSH) in many of the studies, with a proportion ranging from 10 to 72% of all suicides.[5] Near hanging has a significant amount of morbidity and mortality associated with it and the outcome for the patients depends on the degree of brain damage. Outcomes range from complete neurological recovery to a devastating brain injury including brain death.[6] The major cause of the mortality associated with hanging is because of the hypoxic brain injury with other complications being myocardial stunning/Takotsubo cardiomyopathy, and post obstructive pulmonary edema.[7]

With a variation in outcome, a patient may have, the chance complete neuro-psychiatric recovery improves if aggressive resuscitation is given. This study aims to provide an insight into the profile and the outcome of patients that present with near hanging to the adult Emergency Department (ED) of a tertiary care centre in South India.


  Methods Top


Study design: This was a retrospective study on patients presenting with near hanging as a mode of DSH.

Study setting: The study was conducted in the ED of a large tertiary care hospital in South India. The ED is a 50-bed department and tends to have about 300 patients per day, including DSH and other medical/surgical emergencies.

Participants: All patients with DSH who presented to the ED between January 2017 and December 2018 were screened.

Inclusion criteria: All patients presenting with near hanging as a mode of DSH were included in the analysis.

Exclusion criteria: Patients presenting with other methods of DSH and those brought dead were excluded from the analysis.

Variables: The patient data were retrieved through the ED triage registry software and the hospital electronic database. The variables included were age, sex, time of arrival to the ED, comorbidities, presenting complaints, physical examination findings, materials used for hanging, treatment administered, and outcome of these patients at the end of the hospital stay.

Bias: This is a retrospective cohort study and therefore could not control exposure

outcome assessment and instead relied on others for accurate record keeping.

Statistical analysis: Analysis was done using Statistical Package for Social Sciences for Windows (SPSS Inc. Released 2015, version 23.0. Armonk, NY, USA). Continuous variables are presented as mean (standard deviation). Categorical and nominal variables are presented as percentages. Bivariate analysis assessing the factors associated with a bad outcome was performed. For all tests, a two-sided P value less than 0.05 was considered statistically significant.

Ethical considerations: The study was approved by the Institutional Review Board (IRB Min. No. 11082 dated 14/12/2017) and patient confidentiality was maintained by using unique identifiers and by password-protected data entry software with restricted uses.


  Results Top


During the 2-year study period, a total of 156 patients who presented to the ED with near hanging were screened. Twelve patients from the 156 could not make it alive till they reached the ED and were pronounced as dead on arrival and hence were excluded from the analysis. The final study cohort contained 144 patients with near hanging [Figure 1]. The baseline characteristics are shown in [Table 1]. There was no gender disproportionality and a number of men presenting with near hanging were almost equal to that of the women (50.7% vs 49.3%). The mean age (SD) was found to be 33 (12.9) years. Almost half of the patients (46.5%) presented to the ED during day time, i.e., 8 am to 5 pm. Most of them (84%) were categorized as triage priority I at ED arrival. One tenth (9.7%) of them had a known psychiatric illness, whereas a quarter of them (22.9%) were under the influence of alcohol at the time of the incident. The cases of near hanging peaked during the months of February to April and had a second peak in the months of July to September.
Table 1: Baseline characteristics (n=144)

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Figure 1: STROBE diagram

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Majority of the patients used a saree as a material to hang themselves (52.8%) followed by a rope (20.8%), dupatta (16%), and cable wires (7.6%). Half of the people opted to hang themselves because of the reasons unknown to others followed by a domestic fight with the spouse (37.5%). Around half of the patients (49%) presented to the ED in less than 2 hours. The majority of the patients were found hanging for a duration of fewer than 5 min (47.2%), whereas the duration of hanging was not known in 30.6% of the patients.

On examination, the majority of the patients presented with tachypnoea (84.7%), tachycardia (46.5%), and a Glasgow Coma Score (GCS) of less than 8 (47.9%). On performing an arterial blood gas analysis, 24.3% of the patients had significant metabolic acidosis [Table 2].
Table 2: Examination findings at initial presentation

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Of the 144 patients, 58.3% were admitted to the hospital, whereas 20.8% were discharged stable after 24 hours of observation, 19.4% of the people left the ED against medical advice, and a small percentage succumbed to their ordeal (1.4%). Of the patients admitted as in-patients, the majority (92.7%) were discharged stable, 4.8% left against medical advice, and 2.3% died in the hospital [Table 3].
Table 3: ED and hospital outcomes of patients

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On a bivariate analysis of different parameters, it was found that none of the factors had any effect on predicting a good or a bad outcome for the patient. A “bad outcome” was defined as a patient being hemodynamically unstable or with a bad prognosis or patients who left against medical advice, and a “good outcome” was defined by patients being discharged stable after admission [Table 4].
Table 4: Bivariate analysis of factors associated with a bad outcome in near hanging

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  Discussion Top


The objectives of this study were to document the demographic profile, incidence, materials used, outcome, and look for complications present in the patients that presented with hanging as a mode of DSH to the ED of a tertiary care center in South India. The number of patients that presented with hanging was lesser than the lower limit of the national average (8.6 vs 10%).[5] In this study, there was a very slight male predominance, whereas other studies published in India as well as internationally show a high male preponderance committing the act of suicide by hanging.[8],[9],[10],[11] This study found a small percentage to have a documented psychiatric illness and almost a quarter to be under the influence of alcohol. There was also a peak seen during the national examination period and during the local wedding season which indicates that people attempted to hang themselves after succumbing to the pressure of failure in academics or forced marriage. A saree is present in almost every household leading to it being the most commonly used ligature material. The majority of the patients were found hanging for a duration of fewer than 5 min and were brought to the ED in less than 2 hours. However, when enquired in the ED, in the majority of cases, it seemed to still be a mystery for the family members as to why the patient opted to take such an extreme step. This probably is because of the initial shock, denial, and grief the family members would be encountering on arrival at the hospital.

There was a variation observed in comparing our data with other studies from different parts of the world, such as the United States of America (USA) and Iran [Table 5]. It is important to note the different socio-cultural backgrounds in these countries, with USA being an advanced open society and Iran being a conservative society. However, the studies from USA and Iran were from tertiary care referral hospitals, similar to our hospital set up and hence comparable. In the USA, Mansoor et al. reported that three-fourths of their patients were male, whereas Solhi et al. in Iran noted that all the patients that retorted to hanging were males.[11],[12] The mean age of hanging in both these populations was much lesser than our study population and few patients presented with a very low Glasgow Coma Score of 3. This may have led to much intubation rates in this study setting than in the USA but the highest intubation being in Iran. Even then, the in-hospital mortality in our population was significantly lower than in both the cohorts in the USA (5%) and Iran (9.3%). Nick Adams et al.[10] reported that almost half the patients were under the influence of alcohol when they committed the act of hanging. This was almost twice when compared to our study.
Table 5: Comparison of profile and outcome with other studies

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A 12-year study performed by Shilpa D'sa et al.[13] in a Neuro Intensive Care Unit in a tertiary care center in South India reported that the number of males was slightly lower than this study. In this study, it was found that there were a greater number of people who attempted previous self-harm compared to D'sa et al.[13] The use of saree as a ligature material was significantly reduced and more alternative materials were used as a ligature. The number of patients being hypotensive was much higher in the ED. The in-hospital mortality rates were 5.57 times more in the Neuro Intensive Care Unit when compared to the ED. Five years ago, Ganesan et al.[14] reported the incidence of near hanging as 5.3% which suggests that the incidence of near hanging currently has significantly increased to 8.6%. On a bivariate analysis of different parameters, it was found that none of the parameters had any effect at predicting a good or a bad outcome for the patient. This meant that every patient should be offered an aggressive resuscitation as the patient has a good chance of making a complete neurological recovery and living a normal life after psychiatric rehabilitation.

As important as it is to keep the aforementioned points in mind, one must bear in mind that in a developing country like India, the biggest challenges treatment providers face is the cost of providing aggressive resuscitation, and the resources for the same are limited. Also, in a country where discussing mental health comes with a huge stigma, it is quite difficult to provide adequate counselling to the people in need. However, the ultimate solution to tackle this issue still stays avoidance. In the study setting, all the patients who were discharged and stable were referred to the psychiatry department to avoid another attempt of a DSH.

Scope of future research: As a follow-up study, a prospective study could be undertaken to thoroughly evaluate the various factors in a more uniform manner that could later form guidelines for the management of Near Hanging. Most of the patients were stable on discharge but are lost to follow-up in the long run and no data about any late complications are present. A study aiming for a visit 6 months later to the hospital and a thorough examination to look for the late complications and their sequelae by Ultrasound and Radiographic imaging could be performed. A prospective study could thus evaluate long-term outcomes and standardize the treatment.

Limitations

The retrospective nature of the study limited the ability to thoroughly collect data in a uniform way with some instances of missing data in some of the hospital records. The tertiary-level nature of the hospital also may induce an inherent referral pattern bias.


  Conclusions Top


Near hanging comprised a significant proportion of the method of DSH used. The most common materials used are saree and rope. Through this study, it was found that one-fifth of the patients had a bad outcome that was independent of most underlying baseline factors. There was a wide spectrum in the demographic profile and outcome of victims of near hanging across the world and time periods. With a significant number of patients having underlying known psychiatric disorder and being under the influence of alcohol, more vigilance is needed for these patients to prevent DSH attempts.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. 11272 dated 25/09/2019. The authors also certify that they have not plagiarized the contents in this submission and have done a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO | Suicide data. WHO. World Health Organization. Available from: https://www.who.int/news-room/fact-sheets/detail/suicide. [Last accessed on 2020 May 22].  Back to cited text no. 1
    
2.
Wallace SK, Cohen WA, Stern EJ, Reay DT. Judicial hanging: postmortem radiographic, CT, and MR imaging features with autopsy confirmation. Radiology 1994;193:263–7.  Back to cited text no. 2
    
3.
Cooke CT, Cadden GA, Margolius KA. Death by hanging in Western Australia. Pathology (Phila) 1995;27:268–72.  Back to cited text no. 3
    
4.
Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging—A retrospective analysis. Resuscitation 2009;80:210–2.  Back to cited text no. 4
    
5.
Rana A, Nadkarni A. Suicide in India: A systematic review. Shanghai Arch Psychiatry 2014;26:69–80.  Back to cited text no. 5
    
6.
Sutcliffe WJ, Saayman AG. Hanging and asphyxia: Interventions, patient outcomes and resource utilisation in a UK tertiary intensive care unit. J Intensive Care Soc 2018;19:201–8.  Back to cited text no. 6
    
7.
Atreya A, Kanchan T. Clinico-epidemiological study of near-hanging cases – An investigation from Nepal. J Forensic Leg Med 2015;33:35–8.  Back to cited text no. 7
    
8.
Kanchan T, Menezes RG. Suicidal hanging in Manipal, South India-victim profile and gender differences. J Forensic Leg Med 2008;15:493–6.  Back to cited text no. 8
    
9.
Ambade VN, Kolpe D, Tumram N, Meshram S, Pawar M, Kukde H. Characteristic features of hanging: A study in rural district of Central India. J Forensic Sci 2015;60:1216–23.  Back to cited text no. 9
    
10.
Adams N. Near hanging. Emerg Med 1999;11:17–21.  Back to cited text no. 10
    
11.
Solhi H, Pazoki S, Mehrpour O, Alfred S. Epidemiology and prognostic factors in cases of near hanging presenting to a referral hospital in Arak, Iran. J Emerg Med 2012;43:599–604.  Back to cited text no. 11
    
12.
Mansoor S, Afshar M, Barrett M, Smith GS, Barr EA, Lissauer ME, et al. Acute respiratory distress syndrome and outcomes after near-hanging. Am J Emerg Med 2015;33:359–62.  Back to cited text no. 12
    
13.
D'sa SR, Nair S, Joe Philip V, Reji KK, Karuppusamy R, Joseph M. Study of the factors at admission predicting the outcome in patients with attempted suicidal hanging. Trop Doct 2018;48:3–6.  Back to cited text no. 13
    
14.
Ganesan P, Jegaraj MK, Kumar S, Yadav B, Selva B, Tharmaraj RG. Profile and outcome of near-hanging patients presenting to ED in a Tertiary Care Hospital in South India – A retrospective descriptive study. Indian J Psychol Med 2018;40:205–9.  Back to cited text no. 14
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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