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Epidemiology Emergency Medicine Practice. 7. However, since hanging causes a blood pressure drop and strangulation causes a backup of pressure into the head due to vessel constrictions, on autopsy one may find more signs of hemorrhage (retinal hemorrhages) and swelling (brain edema) during strangulation than accurate hanging. Overhanging these recommendations is the understanding that “There is not enough experience to present an evidence-based approach for the use of the CTA.” The author then goes on to recommend CTA for patients who remain unconscious after ED arrival or exhibit unilateral neurologic signs9. A common method for suicide, hanging presents EPs with the question of whether imaging is necessary. Medical crew treating me snapped a phone picture of me. This may be as subtle as hyperemia or as obvious as ecchymosis or abrasions. There are some distinct physical findings that would differentiate the two. First you have the patients who show little to no evidence of trauma and or vascular congestion, who are and have remained conscious and have no neurologic deficits. Most of the strangulation deaths are homicidal in nature. Pulmonary complications are frequently responsible for delayed mortality in survivors of near-hanging and strangulation. In patients not requiring emergent or early intubation, serial exams are crucial. These are referred to as Tardieu’s spots and occur when the venous pressure rises as the ligature tightens resulting in congestion and capillary rupture. Strangulation vs. Choking (02:00) Choking is when an object gets in the airway internally. On EMS arrival he was noted to be groggy but awake and alert, breathing spontaneously with normal breath sounds. In many cases, physical findings are completely absent in non-fatal strangulation. Three states still have this form of execution as an option if lethal injection is not available (DE, NH, WA). A 68-year-old man was found dead in his hut-like home in the autumn of 2000. 9. A 31-year-old male was brought in by ambulance after attempting to hang himself. Dominic Gascho, Jakob Heimer, Carlo Tappero, Sarah Schaerli, Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy – a systematic review, Forensic Science, Medicine and Pathology, 10.1007/s12024-018-0070-z, (2019). Non-judicial hangings are those that occur in homes and jails. Attempted to in past. It is important to re-evaluate frequently for evidence of progressive airway or vascular compromise, such as dyspnea, dysphonia, stridor, drooling, bruits, and focal neurologic deficits. It boasts sensitivities up to 100% (for clinically significant injuries). Intimate Partner Violence: A Health-Based Perspective. However,  the results of the financier’s autopsy suggest he sustained trauma consistent with hanging (after preliminary reports suggested strangulation). Daliah Wachs is a guest contributor to GCN news, her views and opinions, medical or otherwise, are her own. Clinically these patients can be divided into 3 main groups. Non-fatal manual strangulation is likely underestimated and under reported, especially in the setting of intimate partner violence. The majority of hanging victims are males. Someone with no signs of trauma and no neurologic symptoms should just require a period of observation, if anything, following initial evaluation. Suicide by Strangulation („Suspension hanging“) Suspension hanging will kill its victims in three ways: compression of the carotid arteries , the jugular veins , or the airway . These include pulmonary edema, aspiration pneumonitis/pneumonia, and adult respiratory distress syndrome (ARDS). Hanging was strictly defined as a ligature around the neck with only the body weight for suspension. It is the best modality for assessing the deep soft tissues, larynx, and vessels; however, it is not as readily available from the ED and its cost and time requirements make it less appealing for routine use. They are usually not associated with any significant drop and frequently lead to incomplete suspension, with part of the victim’s body still in contact with the ground. MRI is the best imaging modality for deep soft tissue injury and edema. 6. External compression of the airway structures requires significantly more force than the vascular structures and this is not thought to play a significant role. He was unconscious when he was cut down and had been hanging for an unknown amount of time. For this reason, hangings in the past were broadly categorized as judicial or non-judicial. There is inadequate experience or data to recommend an evidence-based approach to imaging in strangulation or near-hanging victims. . Clinical Features Pulmonary sequelae are frequently seen in survivors of near-hanging and strangulation as well. The majority of hanging victims are males. Strangulation: A review of ligature, manual, and postural neck compression injuries. Testosterone Therapy: New guidelines released, Cervical cancer awareness: The simple scoop on pap smears, Easy and practical New Year’s Resolutions. Recommendations for group two the most severely injured are ABCD stabilization and admission to the appropriate level of care. Defensive marks may also appear on the neck in the form of abrasions/fingernail scratches. Cricoid fractures are touted as the most serious of laryngotracheal injuries; being the only complete ring, fracture of this structure can rapidly lead to complete airway obstruction. Plain films utility in determining life threats or helping the physician disposition their patient is limited. A very busy Level I trauma center reviewed their registry for adult near-hangings over a 19 year period. Accidental and self-strangulation death are very rare to meet in practice. Other patients encountered in the ED may be survivors of manual or ligature strangulation with the forces applied to the neck being independent of the victim’s body weight. The ligature material can be any household substance. Judicial Hanging. In Berlin (3.5 million inhabitants; ca. Hanging is the most common method of suicide in Malaysia. The disadvantage of this method is that ultrasound has a lower resolution than CT and thus, lower sensitivity. These type of things created so many problems for the people and the society also, in this situation so many people got dead and many people admit in the hospital and treatment for the curing. A2A Manual strangulation, aka throttling, is with the bare hands or an object such as a pipe or a baseball bat. Strangulation is when external pressure is applied to the neck obstructing airflow and blood flow. Ultimately it seems as though there are several modalities available to us when evaluating strangled patients. A wooden bar passed through the circle created by the belt on the right side of the neck (ie, the tourniquet method). In 2009, 2.4% of murders were secondary to “strangulation” or “asphyxiation”1. However, one retrospective case review of near-hangings over a 10-year period at LA County and University of Southern California Medical Center found a cervical spine fracture incidence of nearly 5%9. Fracture of non-calcified cartilages may not be readily apparent on plain film and further imaging should be pursued if this is suspected. Garroting or ligature strangulation involves pressure being applied to the neck by a ligature just as in hanging. STRANGULATION Strangulation is the form of asphlxia caused by constriction of neck by ligature or some other method, but without suspension of the body. 2,4,5. Another proposed mechanism for the cause of death relates to vagal reflexes resulting from external pressure on the carotid body, which can lead to extreme bradycardia and cardiac arrest. Strangulation is a type of mechanical asphyxia produced by constriction of the neck by ligature material, without suspending the body . A type of hanging comparable to full suspension hanging may be obtained by self-strangulation using a ligature around the neck and the partial weight of the body (partial suspension) to tighten the ligature. At page No. Fractures of bony and cartilaginous structures in the neck are common, reported in both near-hanging and strangulation victims. The same mechanism leads to subconjunctival hemorrhages. His voice sounds normal to you and to the patient. Petechial hemorrhages on conjunctiva, mucous membranes, and skin cephalad to ligature are another common feature (as shown in image 2). CT is much more sensitive for bony, cartilaginous, and soft tissue injuries, subcutaneous emphysema, edema, and hemorrhage. However, it is still recommended that precautions be taken to stabilize the cervical spine until such injury can be appropriately excluded. « This year’s predictions for upcoming hurricane season, Weird News: The Impossible Burger vs. Vander Krol L, Wolfe R. The emergency department management of near-hanging victims. Stapczynski, J. Stephan. Its sensitivity is reported as 80-90%. The true incidence of manual strangulation is unknown. Clarot F, Vaz E, Papin F, Proust B. Iserson KV. If I were a lawyer or an investigator that handle this type of case, I’ll make sure to work with a service that specializes in strangulations because they’ll be able to help me present evidence that can be used in the court. Patients that require imaging who are stable enough for CT scan or MRI will get little to no benefit from a pre CT/MRI Plain Film. Injury to any of these structures puts patients at risk for airway obstruction from edema. Neck Trauma: Don’t Put Your Neck On The Line. 7, 8, 15, 16, and 50 and Fig. Manual strangulation occurs when one person uses their hands, another extremity, or an object of some sort to block airflow in another person. He was unconscious when he was cut down and had been hanging for an unknown amount of time. United States Census Bureau; Statistical Abstract of the United States; 2012. of sex trafficking charges, was found dead in his jail cell on August 10. It’s worrying to know how many things can go wrong when something gets fractured around the neck area due to strangulation. Differentiation from hanging Ligature strangulation mark usually not mimic hanging, except strangle with ligature and then pull along the ground from the free end of the ligature resulting an inverted V appearance at the knot mark. 1. Fortunately cricoid injuries are rare. Doctor Wachs is an MD,  FAAFP and a Board Certified Family Physician. 2 Aug 2010. A history of drug or alcohol abuse is seen frequently among hanging victims, as is psychiatric illness2. When done properly, this resulted in forceful distraction of the head and neck from the body, high cervical fracture, complete cord transection, and death. This is frequently the cause of accidental asphyxiation in children. Presenting signs and symptoms vary depending on mechanism. The Dr. Daliah Show , is nationally syndicated M-F from 11:00 am - 2:00 pm and Saturday from Noon-1:00 pm (all central times) at GCN. Other frequently reported symptoms include voice changes (from hoarseness to aphonia), odynophagia, dysphagia, dyspnea, neck or throat pain, altered mental status and neurologic symptoms. Group 3 will be the group that requires that the provider decide imaging (CTA vs. MRI vs. observation), and if observation is decided then 12 hour vs. 24 hour. 8. Our patient underwent a 6-hour observation period and was deemed medically stable for a psychiatric evaluation. Drop is at least as long as the height of the victim, hanging is complete; Head hyperextends => Fracture of upper cervical spine, most commonly traumatic spondylolisthesis of C2, “hangman’s fracture” Transection of the spinal cord . Imaging Self-strangulation by ligature is uncommon . Doctor Wachs is an MD,  FAAFP and a Board Certified Family Physician. Hand prints or remnants of an object will most likely be visible on the neck. Schaider J, Bailitz J. When a suicidal hanging involves partial suspension the deceased is found to have both feet touching the ground, e.g., they are kneeling, crouching or standing. Two … Hanging was historically used as a method for execution. Diagnostic Considerations More than half were aged 15-44 years1. Several paragraphs later the author discusses MRI stating “There is not enough experience with MRI to present an evidence-based decision tool for its use in strangulation victims.” His recommendation is that MRI be done in patients who are awake but report a loss of consciousness during the strangulation episode or have facial or conjunctival petechiae. Women are much more likely to be victims of strangulation assaults than men. Strangulation occurs when one compresses the structures of the neck causing decrease air and blood flow. If you want to know what professional craftsmanship looks like, this is it. The compression is usually applied to the neck by using the decedent's own body weight in what would generally be described as either a partial or complete hanging. Chapter 16:217-35. When a wire or cord is used, it often completely encircles the neck. Is this a violation of hippa? The furrow is typically at or above the thyroid cartilage prominence (notch, Adam's apple) in contrast to ligature strangulation, in which the furrow is typically on or below the thyroid cartilage (refs. Neurogenic pulmonary edema results from a centrally-mediated, massive sympathetic discharge after anoxic brain injury. J Emerg Med 1994;12:285-92. Incidences reported in the literature range from 10-68% for non-fatal strangulation in intimate partner violence3. 1). Fuck this. The distance of the drop is crucial in determining the success of the execution. The third and the final group include patients with voice changes, petechial and or evidence of trauma from the strangulation. Three states still have this form of execution as an option if lethal injection is not available (DE, NH, WA). The relatively superficial and unprotected jugular veins in the neck are quite vulnerable to compression by external forces. I don’t know what I am doing wrong….I guess I just have too much neck muscle for this to be a feasible method of suicide…which is a shame since I don’t own a gun and I don’t have a suitable place to do a full on suspension hanging in my apartment. 5. There was no issue with his airway, vascular or neurologic systems and the patient was cleared by Psychiatry the next day and discharged home. Both thrombosis and thromboembolism can lead to delayed neurologic signs and symptoms. MRI seems to give the most information regarding the direct injury to the soft tissues and vessels and further information regarding neurologic injury to the central nervous system. People with no neurologic injury but with evidence of trauma and or petechial or subconjunctival hemorrhage seem to merit some sort of imaging although exact recommendations are not available at this time. The circle was constricted by rotating the bar, thus placing pressure on the neck. Fiber optic laryngoscopy is useful to evaluate the soft tissues of the oropharynx but tells us little about the deeper soft tissue injuries. A total of 125 patients were analyzed, and were grouped into patients presenting with a normal GCS (15), and those who were abnormal (<15). Dr. Sherly Vasu on Postmortem Findings in Cases of Hanging and Ligature Strangulation The official YouTube channel for Manorama News. Int J Care Injured 2006;37:435-39. Perimortem hyoid fracture frequently indicates manual strangulation, although ligature strangulation, hanging, and other forms of trauma to the neck cannot be ruled out without additional evidence. . He was found hanging from a tow rope in the back yard by his brother who immediately cut him down. “Strangulation Injuries.” Emergency Medicine Reports. He had recently been on suicide watch and reports initially suggested he had hung himself by his bed sheet. Diagnosis requires a high index of suspicion, as patients are frequently asymptomatic immediately after the injury. Definition: external pressure on neck resulting in compression of blood vessels and occasionally airway ; Strangulation: neck compression due to something other than the victim's body weight, such as manual compression or ligature tightened by assailant; usually homicidal . 286 it was also stated of the distinction between suffocation and strangulation that conditions associated with mechanical asphyxia include suffocation where the interference with the process of breathing is at the level of the nose or mouth; strangulation where there is compression of the neck, either by (a) the human hand (manual strangulation or throttling); (b) a ligature. I also never knew that2.4% of murders are due to strangulation or asphyxiation. Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. 2012 Dec. 33(4):339-40. . It could be executed using a ligature (scarf, sheet, cord) or by one’s hands. Obstruction can be delayed, rapid, and life-threatening, making close airway monitoring a must. 2. With hanging, one drops from a height and suspends, incurring a fracture of a neck bone which in turn may sever the spinal cord. The true incidence of manual strangulation is unknown. Dr. Ashley Menne is a 4th year EM Resident at the Denver Health Emergency Medicine Residency Program. In 2009, 2.4% of murders were secondary to “strangulation” or “asphyxiation”1. The most extensive review of imaging modalities for strangulation victims by Stapczynski in 2010 gives recommendations based on clinical scenarios in terms of which type of imaging to pursue. A drop to long could cause beheading, a drop too short could cause strangulation. Taliaferro E, Hawley D, McClane G, Strack G. “Strangulation in Intimate Partner Violence”. How do forensic experts tell the difference? Common features include evidence of external pressure on the skin of the neck by the ligature, assailant’s hands, or other object causing strangulation. Many times the hyoid bone is fractured (1/3 of all homicides) as its think U-shape is vulnerable to the forces of strangulation. The direction of the furrow on the decedent's neck can help the examining physician determine whether the cause of death was a hanging or a strangulation -- but it … Written by Dr. Daliah Wachs, 66 year-old Jeffrey Epstein, who recently pleaded. The most severely injured and the least severely injured are the two groups that you can decide imaging most easily. Other, more common injuries are hyoid bone fractures and laryngeal fractures and contusions. Am J Forensic Med Pathol. A history of drug or alcohol abuse is seen frequently among hanging victims, as is psychiatric illness2. 4. J Emerg Med 2011;40:355-58. If they do strangulate ...they asphyxiate (lose air flow), or lose blood flow from their carotid arteries being compromised. Plutonium “smuggled” into site near Las Vegas…..What are the health impacts? Blunt vascular injury is rare but is thought to be one of the most underdiagnosed injuries and may have devastating delayed complications. In postmortem hanging, the corpse has to be moved and placed in the position of strangulation. Weight of the body has nothing to do with strangulation. Plain radiographs may show signs suggestive of laryngotracheal injury, such as subcutaneous emphysema, tracheal deviation from edema/hemorrhage, or hyoid bone fracture. The Marrot! So the force constricting the neck is external force (not the weight of the body as occurs in hanging). Classically, a judicial hanging involved a ligature with careful knot placement directly below the occiput and a drop equivalent to the victim’s height with abrupt tightening of the ligature and complete suspension of the entirety of the victim’s body weight. Cervical spine fractures are also uncommon in manual strangulation. Management and Disposition Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. More than half were aged 15-44 years1. Volume 5, Number 7. One of my friends is considering to file a divorce soon due to a few instances of domestic abuse. It sometimes is called throttling. Carotid Doppler ultrasound is an alternative method for diagnosis of carotid injury and it has the advantage of being readily available, portable, and does not require radiation or IV contrast. Hanging is the second most common form of suicide in the United States after firearms, accounting for 23% of the over 34,500 suicides that occurred in the year 2007. Case Conclusion As seen above, a “hangman’s fracture” is seen with hyperextension injuries where the pars interarticularis on the pedicle of the C2 vertebrae becomes fractured. Cervical spine fractures are well-documented in judicial hangings but are thought to be exceedingly rare or non-existent in non-judicial hangings. Some cases of suicidal hanging, however, do show the furrow at the level of the thyroid cartilage (134). Pathophysiology Once the obstruction is removed, pulmonary edema develops and can rapidly lead to ARDS. A 31-year-old male was brought in by ambulance after attempting to hang himself. Postural strangulation is the term applied to compression of the anterior neck against a firm object and also involves the victim’s body weight. There was no sign of forced entry to the door of the house. 500 suicides per year) approximately one case per year occurs. As with any ED patient, airway management is the initial priority. Moreover, it can occur if a hanging drop is improperly calculated. Strangulation causes asphyxia. So injuries incurred can be similar in both strangulation and hanging, especially if the latter is done improperly and ineffectively severs the spinal cord. It has been reported in both near-hanging and strangulation victims. He had recently been on suicide watch and reports initially suggested he had hung himself by his bed sheet. Ligature strangulation: the ligature mark on the neck is usually horizontal ; If homicidal (most common), may … For this reason, near-hangings are associated with very different pathophysiology and injuries than complete, judicial hangings. Copyright © 2019 EPMonthly.com | Web Design by Transfuture, Clinical Focus: Strangulation and Hanging Injuries, Spanish Influenza – Looking at a Pandemic From 100 Years ago, EPM Talk Ep. The difference is that the force used to exert this pressure is something other than the individual’s body weight. The body is heavy, and characteristic findings are therefore usually present at the scene and on the body [ 24 , 32 ] (e.g., variable excoriations of the … ”, -David Brooks, New York Times Op/Ed Editor. Suicides by ligature strangulation are rare events. Vilke G, Chan T. Evaluation and Management for carotid dissection in patients presenting after choking or strangulation. About 5 kg of pressure is required to compress the carotid artery; 2 kg for the jugular veins; and at least 15 kg for the airway. When the fa… July 2003. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: A 10-year experience. The pattern of these injuries allows us to recognize strangulation as a mechanism, and to distinguish strangulation from other blunt injuries including hanging, traumatic blows to the neck, and artifacts of decomposition. Background Strangulation. Often hanging can have the same marking on the body as ligature strangulation as they are technically the same thing, but with different processes. The role of the carotid sinus reflex in strangulation and near hanging is disputed and believed to be relatively uncommon. Maybe backing up her claims with medical records that prove instances of strangulation will help make the process faster for her. Sauvageau A, Ambrosi C, Kelly S. Three nonlethal ligature strangulations filmed by an autoerotic practitioner: comparison of early agonal responses in strangulation by ligature, hanging, and manual strangulation. 12). The best and safest technique for intubation is controversial but oral intubation, if necessary, is safe in most. People that remain unconscious or have signs of neurologic injury will need further imaging be it MRI or CTA. The ligature mark completely encircles the neck in strangulation, while in hanging it is absent near the point of suspension. Obstruction of venous outflow from the brain leads to stagnant hypoxia and loss of consciousness in as little as 15 seconds. Children and individuals who practice autoerotic asphyxiation are the most common victims of accidental hanging (1). This can help us identify patients who may need further imaging or observation. You wonder if you should get a CT angiogram or if he needs just observation, or if he can be safely discharged soon. However, hanging in combination with suicidal ligature strangulation is uncommon. Pain with movements of the tongue or with swallowing may imply injury to the epiglottis, hyoid bone, or laryngeal cartilage. Such fractures are rare in children and infants, since the hyoid components are not fully ossified and are more flexible than in adults. Key Words: Hanging, Ligature strangulation, Hyoid Bone, Thyroid Cartilage, Compression of neck Introduction: Violent asphyxial deaths is one of the most important cause for unnatural deaths among which hanging and ligature strangulation are commonly encountered in the professional life of forensic expert during day to day autopsy. Depending upon the method used to constrict the neck, strangulation can be divided into: Other Strangulation Injuries in suicide) or intentional (e.g. Strangulation occurs when one compresses the structures of the neck causing decrease air and blood flow. Two mechanisms have been proposed as causes for pulmonary edema. These findings supported suspicions that the dry ligature mark had been caused by hanging after her death, and that the light ligature mark with slight subcutaneous haemorrhages on the left side and back of the neck had been caused by strangulation, which had brought on the victim's death. This number is on the rise compared with prior years. 66 year-old Jeffrey Epstein, who recently pleaded not guilty of sex trafficking charges, was found dead in his jail cell on August 10. Imaging should be ordered based on clinical suspicion. The factor of suspension differentiates hanging from strangulation by ligature; the latter being caused by application of a ligature of the neck in such a way that the force acting upon it is other than the weight of the body [4]. Injury is thought to occur from compression of the common carotid artery against the transverse processes of the fourth to sixth vertebrae leading to hemorrhage within the media or intimal disruption. By William Sullivan, DO, JD & Andrew F. Kalnow, DO, “I was entranced by an essay in Emergency Physicians Monthly . In ligature strangulation, in contrast to hangings, the ligature mark usually encircles the neck in a horizontal plane often overlying the larynx or upper trachea (Figure 8.22). Patients may also exhibit dysphonia, aphonia, dyspnea, stridor, hemoptysis, neck tenderness over the larynx, or loss of landmarks of the anterior neck secondary to swelling or overlying hematoma. Hangings are in fact a type of strangulation, along with ligature strangulation and manual strangulation. Jeffrey Epstein's cause of death has been ruled a suicide by hanging; however, there a series of conspiracy theories that suggest he was strangled. CT Angiography is considered by most to be the test of choice when evaluating for blunt vascular injury. He was found hanging from a tow rope in the back yard by his brother who immediately cut him down. Given the potential for delayed and rapid airway obstruction, earlier intubation often leads to easier intubation in this patient population. Dr. Peter Pryor is an Attending Physician at Denver Health and Assistant Professor of EM at the University of Colorado School of Medicine. 5. Hangings and strangulations can all be accidental, self-inflicted (e.g. Forensic Sci Int 2005;149:143-50. 6. Ligature strangulation is a violent form of death, which results from constricting the neck by means of a ligature or by any other means without suspending the body. 3. Victims of judicial hanging are not patients who survive and present to the ED. Regardless of the manner of death, ligature strangulation occurs when an external object is placed around the neck and provides compression. Second, there are the patients that had an episode of unconsciousness or continue to be unconscious requiring intubation or have neurologic deficits. judicial hangings) 3. Post-obstructive pulmonary edema results from excessive negative inspiratory pressures generated by the victim’s attempts to forcefully inspire against an airway obstruction. From a capital punishment standpoint, hanging is one of the most common and barbaric ways to execute. The occurrence of a narrow zone of engorgement or bruising immediately above and below the groove, confirms that the victim was alive at the time when the ligature … ». It’s shocking to learn that hanging is the most common type of suicide in the united states. The first group can be assessed and discharged without imaging or observation period. The inside of the house was neat and undisturbed. Now-a-days hanging is a very serious injury in our society, most of the people hang for the suicide. The resultant decrease in muscle tone allows the external force to tighten further and leads to complete arterial occlusion, brain injury, and death. EPM is the independent voice for emergency medicine, bringing together commentary from the top opinion leaders, clinical reviews from leading educators and quick-hit departments covering everything from ultrasound to toxicology. Ligature strangulation, also called garroting, is the wrapping of a pliable object such as a rope, wire, or shoelaces partially or fully around the neck and pulling it tightly across the throat. This should be a consideration if the patient will be leaving the department for imaging studies or prior to transfer to another facility if necessary. In the ED, his physical exam is notable for ligature marks on his neck (image 1). Definition-Strangulation is defined as the compression of the neck by a force other than hanging. process of strangulation, whether by hand (manual), or by ligature, results in blunt force injury of the tissues of the neck. The victim was lying on his back on the bed and there was a 5 cm-wide, thick fabric belt around his neck (Fig. Hanging—Suspension from a cord wound around the neck; Ligature strangulation—Strangulation without suspension using some form of cord-like object called a garrote; Manual strangulation—Strangulation using the fingers or other extremity A severe blood pressure drop can ensue and the victim may die within minutes. From a capital punishment standpoint, hanging is one of the most common and barbaric ways to execute. 36 – When Minutes Matter: Dr. Este O’Daniell on Syndromic Infectious Disease Testing for Meningitis, EM Quiz: Ill-appearing, minimally responsive patient. Ann Emerg Med 1984;13:179-85. These injuries may present with subcutaneous air or bony crepitus over the larynx. Daliah Wachs is a guest contributor to GCN news, her views and opinions, medical or otherwise, are her own.