Neck Injury by Strangulation/hanging



  • Strangulation:
    • Ligature: Material used to compress structures of neck
    • Manual: Physical force used to compress structures of neck
    • Postural: Airway obstruction from body weight (over an object) or position (typically in infants)
  • Hanging is a form of strangulation:
    • Complete (judicial type): Victim's entire body is suspended off the ground
    • Incomplete (nonjudicial): Some part of victim's body contacts the ground
    • Typical: The point of suspension is placed centrally over the occiput
    • Atypical: The point of suspension is in any position other than over the central occiput
    • Intentional: Suicide, homicide, autoerotic, “choking game”
    • Accidental: Often children or clothing caught in machinery
    • Near-hanging: Survival following nonjudicial hanging


  • Hanging (judicial):
    • Victim is dropped a distance at least equal to his or her height
    • Forceful distraction of head from torso results in a decapitation type of injury (fracture of cervical spine and transection of spinal cord)
  • Hanging (nonjudicial):
    • Typically occurs from a lower height
    • Injuries mimic nonjudicial strangulation
  • Strangulation:
    • Asphyxia by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck
    • Three causes: Hanging, ligature strangulation, and manual strangulation
    • Cervical spine injuries are uncommon except with judicial-type hanging
  • Death:
    • Secondary to mechanical closure of blood vessels or airway
    • Secondary to cardiac arrest from extreme bradycardia due to increased vagal tone from carotid sinus pressure
    • Secondary to direct neurologic injury to the spinal cord
    • Secondary to pulmonary complications in near-hanging victims
    • Secondary to cerebral hypoxia

Commonly Associated Conditions

  • Cervical spine injury
  • Hypoxic cerebral injury
  • Arterial or venous dissection/thrombosis
  • Hyoid bone fracture:
    • Typically seen in nonjudicial strangulation
  • Cricoid cartilage disruption (rare)
  • Thyroid cartilage disruption:
    • More common in nonjudicial strangulation deaths
  • Phrenic nerve injury
  • Airway edema
  • Acute respiratory distress syndrome (ARDS)
  • Aspiration pneumonitis (may be late)
  • Neurogenic pulmonary edema (may be late):
    • Due to massive central sympathetic discharge
  • Postobstructive pulmonary edema (may be rapid onset):
    • Due to negative intrapleural pressure resulting from inspiration against an external airway obstruction
  • Air embolism:
    • Consider when subcutaneous (SC) air and vascular injuries are present

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