All critical structures (blood flow and return; muscular and bony support; air entry and exit; alimentary system entrance) that the body requires to function, even at the most basic level, travel though the neck. However, the neck has a relatively small diameter and is exposed to the environment without any protective shielding; accordingly, it is vulnerable to numerous life-threatening injuries. Disruption of this critical location, such as occurs with strangulation or hanging, can lead to disability and even death.
Strangulation causes death and disability in either of two ways: (1) asphyxia through closure of air passages or (2) occlusion of the blood vessels that supply the brain in the neck as a consequence of external pressure. Hanging is the suspension (complete or incomplete) of a person's body, with compression due to the body's own weight. What many people consider to be hanging is not actually hanging, in that death occurs by fracture or dislocation rather than asphyxia.[1]
Evidence of strangulation includes the following[2, 3] :
Evidence of hanging includes the following[5, 6, 7, 3] :
Judicial hangings are characterized by drops from heights that are greater than the victim's height. In such drops, the head hyperextends as the noose stops the victim. Classically, the result is bilateral fracture through the pedicles of C2; the body of C2 is displaced anterior to the vertebral body of C3. This leads to fracture and spinal cord transection. In nonjudicial hangings, cervical spine injury is rare; however, laryngeal injuries can result.[8] Traumatic vascular thrombosis can occur as a result of the pressures placed on the vascular structures by the ligature. Such injuries can also be caused by strangulation with a cord (garroting).
When a person is strangled (either intentionally or accidentally) or hanged, the pathophysiology starts with decreasing blood flow and air flow, leading to cerebral hypoxia and death.[9, 10] Venous obstruction leads to cerebral blood flow stagnation, hypoxia, and unconsciousness. This loss of consciousness causes complete loss of muscle tone. The weight of the body then allows the offending tool to access the cerebral arteries and airway, hastening the hanging. Arterial spasm may occur due to carotid pressure, leading to low cerebral blood flow and collapse. Death occurs from cerebral hypoxia and ischemic neuronal death.
The mechanism of death from hanging is effectively decapitation, with distraction of the head from the neck and torso, fracture of the upper cervical spine (typically traumatic spondylolysis of C2 in the classic hangman fracture), and transection of the spinal cord.[11] Direct spinal cord injury (SCI) may or may not be the cause of death in suicidal hangings.
Toddlers can succumb to strangulation by postural asphyxiation—for instance, when their necks are caught between the slats of a poorly constructed crib, and strangulation occurs as they try to pull their heads out. Window cords may also result in death, tightening around the necks as children try to free themselves.[9, 10]
Adolescents are more prone to the effects of strangulation as a result of a suicidal attempt from depression or accidental hanging. They can also experience strangulation as a result of life-threatening "games" such as the "choking game" or autoerotic asphyxiation.
According to a 2024 report from the National Center for Injury Prevention and Disease Control’s National Violent Death Reporting System, suicide from hanging, strangulation, and suffocation accounted for 26.2% of suicides in the United States in 2021, second only to suicide by firearm (54.3%).[12] In a 2025 study of suicide and suicidal ideation in British military veterans, suicide by hanging or strangulation was the most common type, with suicide by firearm accounting for only 2% of deaths.[13]
Accidental hanging and strangulation injuries have become more prevalent in urban centers,[14, 15] a development that is likely related to increased prevalence of the "choking game" and autoerotic "breath play."[16, 17, 18]
In a study of 622 hanging deaths by Tugaleva et al, hyoid and larynx fractures were present in 46 cases (7.3%), with isolated hyoid fractures accounting for the largest percentage of these injuries.[19] The incidence of cricoid fractures was 0.5%, and the incidence of cervical spine injuries was 1.1%.
A survivor of a strangulation or hanging attempt can have permanent damage to any of the structures in the neck, along with central nervous system (CNS) disability. Trauma to and occlusion of the carotid artery can lead to carotid artery dissection and strokelike symptoms, which may not be reversible. If the brain cannot be reperfused in that area, these stroke symptoms (eg, speech difficulty, gait difficulties, and swallowing difficulties) may be permanent. Global hypoxia can lead to traumatic brain injury (TBI), resulting in cognitive difficulties, decision-making disabilities, and personality or behavior disorders requiring long-term care.[20, 21, 22, 23, 24]
For patients who have attempted hanging or have experienced prolonged strangulation, the prognosis is poor. These patients are usually unconscious on arrival and need advanced airway management to survive. They usually have hypoxic encephalopathy, cervical SCI, and serious respiratory compromise, leading to death.[25, 21, 23, 24] If they survive, they may need long-term care.
Patients who are found to be victims of strangulation must be helped to feel safe, and efforts must be made to ensure that they are in a safe environment and are not experiencing domestic abuse.
Patients need to be made aware of symptoms that may not present until later, such as neck swelling, changes in voice, or difficulties in talking or swallowing—all of which are reasons to return to an emergency department (ED) for care.
A patient may present with a first episode of hanging or strangulation without any history of interpartner violence or hanging.
A history of interpartner violence is a predictor of future interpartner violence, and strangulation is one of the many methods that assailants use as a weapon of control and power. A history of such violence is important because there may be no initial signs or symptoms of strangulation.
When a patient presents with a hanging injury, an evaluation should always be made for a history of depression or suicide attempt.[26] These historical features are notoriously difficult to discern, and patients may not be forthcoming about them, because of the stigmas associated with mental health problems and domestic violence.
A strangulation injury may be asymptomatic. Delayed injury is a real risk, and awareness is important after any type of assault. The initial findings from physical examination can vary widely, ranging from absence of any significant findings to respiratory arrest.
The evaluation should focus on the structures that may be the most affected, which are the carotid arteries and the trachea.
The most common physical examination findings are the result of obstruction of venous return (eg, bruising, edema, or petechiae), obstruction of airflow (hypoxia or anoxia), and direct trauma (laryngeal fracture or hematoma).
Signs and symptoms of strangulation include the following[2] :
Signs and symptoms of hanging include the following:
Complications of strangulation and hanging include the following:
As with any traumatic injury, the workup should begin with evaluation of the patient’s ABCs (airway, breathing, and circulation). Immediate resuscitation should take priority over imaging. A cervical collar or other immobilization device should be immediately applied in any patients who have extensive cervical injury findings from hanging. Most cervical injuries are from hanging, not strangulation.
Once the patient is stabilized, appropriate laboratory studies may be ordered. (See Laboratory Studies.) There are numerous imaging studies that can be initiated in the stabilized strangulated or hanged patient. (See Imaging Studies.) The goal is to make sure that there are no continued active life-threatening injuries (eg, hemorrhage, expanding hematoma, or airway compromise). After stabilization, continued imaging is appropriate to evaluate for various other injuries that can lead to chronic conditions.
Direct fiberoptic laryngoscopy and microlaryngoscopy may be helpful in patients not at immediate risk for airway compromise.
There is no laboratory study that is pathognomonic for or diagnostic of hanging or strangulation. Laboratory tests should not be drawn until after the airway has been assessed and, if necessary, secured. Once the patient is stable, appropriate studies may include the following:
Computed tomography (CT) is the first imaging modality for strangulation injuries, and CT angiography (CTA) is the gold standard for imaging of the carotid and vertebral arteries,[28] allowing evaluation of vascular and bony structures. Noncontrast CT is used to evaluate the brain for signs of stroke and cerebral edema. Magnetic resonance imaging (MRI) is the most accurate study for evaluating soft tissues of the neck.[29] MRI and magnetic resonance angiography (MRA) of the brain have the greatest sensitivity for evaluating global and anoxic brain injury, ischemic stroke, and intracranial hemorrhage.
Given the varied injuries associated with hanging and strangulation and the superiority of CT over plain films in the evaluation of the cervical spine,[8, 30] early CT and CTA should be obtained in any symptomatic hanging survivor. If there is any neurologic abnormality on initial assessment, CT of the head is also indicated. MRI may have a role in further defining injuries found at initial imaging, especially if there are focal neurological findings.[31, 32]
As always, chest radiographs are indicated after endotracheal intubation for placement confirmation and to establish a baseline against which to measure the patient's course. Acute respiratory distress syndrome (ARDS) can occur as a complication of these injuries.
Postmortem CT (PMCT) is used to identify fractures after hanging and strangulation. Decker et al noted that although PMCT may not detect soft-tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equivalent to autopsy in detecting bony injuries and might surpass autopsy in detecting subtle fractures.[33] In an extensive study by Schulze et al, the gas-bubble sign on PMCT had a sensitivity of 79.2%, a positive predictive value of 95%, a specificity of 90.9%, a negative predictive value of 34.5%, and an accuracy of 83% for identifying laryngeal fractures in postmortem hanging victims.[34]
MRI has been shown to be capable of successfully detecting soft-tissue lesions related to strangulation[29] and can serve as an alternative to autopsy or provide additional value to autopsy. Deininger-Czermak et al noted that MRI showed a high efficiency in verifying intramuscular hemorrhages that were confirmed on autopsy.[35, 36]
A systematic review by Gascho et al found that CT, as compared with autopsy, was equally effective in detecting fractures (in this study, mainly fractures of the hyoid bone or thyroid cartilage).[37] The authors noted that the gas-bubble sign might facilitate the detection of laryngeal fractures on CT. With regard to detection of hemorrhages in the soft tissue of the neck, postmortem MRI was found to be more suitable for detecting the gas-bubble sign in cases of strangulation.
In patients who are not at immediate risk for airway compromise, immediate advanced airway placement is indicated; this can be accomplished via either direct laryngoscopy or video laryngoscopy. Regardless of the method employed, it is essential to take into account the concern regarding possible cervical spine injury during the procedure. Fiberoptic laryngoscopy and microlaryngoscopy may play a role in establishing the full pattern of injuries.
Cervical spine stabilization and airway assessment are of paramount importance. Endotracheal intubation should not be attempted in the field unless the airway is acutely compromised while cervical spine immobilization is maintained. If respiratory failure or airway obstruction is present, prehospital intubation of the patient is indicated.
Early consultation with trauma, otolaryngology, trauma, or general surgery should be considered for strangulation injuries. Psychiatric consultation should be obtained in cases of suicidal or autoerotic strangulation.[19, 38]
Assessment and treatment of airway status and breathing are crucial considerations. In assessing the patient before possible endotracheal intubation, it is important to remember that the likelihood of spinal cord injury (SCI) increases substantially in hanging victims whose drop was equal to or greater than their height, even if the hanging was incomplete. Fluid resuscitation must be performed judiciously, given the risk of subsequent acute respiratory distress syndrome (ARDS) and cerebral edema.[10, 20, 22, 38]
The patient should be monitored for cardiac arrhythmias.
Cricothyroidotomy (cricothyrotomy) is indicated for any patient with airway deterioration, should endotracheal intubation be unsuccessful. If associated neck injuries render cricothyroidotomy difficult, percutaneous translaryngeal ventilation may be used for temporary oxygenation of the patient. Definitive airway management (laryngotomy) must follow swiftly.
A cervical collar or other immobilization device should be immediately applied in any patients who have extensive cervical injury findings.
Care of these patients addresses both physical trauma and mental health concerns. As with all traumatic-type injuries, it is vital to make sure that the scene is safe and that the patient is no longer a harm to others or themselves. These situations can carry a strong emotional charge.
Patients must be monitored for airway edema, tracheal injury, and vocal cord paralysis. Fiberoptic evaluation by a specialist (otolaryngologist) is a necessary part of management. This evaluation should be done in conjuction with occupational therapy (OT) and physical therapy (PT) evaluation.
Patients who have undergone hanging or strangulation may experience devastating complications, ranging from strokelike symptoms to complete anoxic brain injury. These injury patterns may necessitate prolonged long-term care.
Otolaryngologists are the specialists most commonly consulted for cases of hanging and strangulation involving the structures in and around the neck. They are asked to assess the trachea and vocal cords, usually via fiberoptic evaluation. Their input is crucial in making the decision as to whether a definitive airway (tracheostomy) is needed.