O3006: Injury Patterns and Associated Mortality in Children with Asphyxiation by Hanging

Background: Asphyxiation by hanging carries significant mortality risk and is the most common means of suicide in US children under 11 years. Children are postulated to have separate mechanisms of injury compared to adult hanging victims and children with other blunt cerebrovascular injury. Given a lack of multi-center data in pediatric hanging, the incidence of secondary injuries, particularly neck arterial injury and cervical spine (C-spine) fracture, remains unknown. The objective of this study was to determine the incidence of secondary injuries and their association with in-hospital mortality in pediatric victims of asphyxiation by hanging.

Methods: We performed a retrospective cohort study of children using administrative data from 45 geographically diverse US Children’s Hospitals. We identified children ≤ 16 years presenting between October 1, 2015 and December 31, 2021 with an "International Classification of Disease, 10th revision" principal diagnosis code of asphyxiation due to hanging (T71.16). We excluded patients with a diagnosis of hanging in the previous 30 days and visits coded as subsequent encounters. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, C-spine fracture, C-spine ligamentous injury, C-spine subluxation/dislocation, cervical cord injury, and neck arterial injury. We performed Fisher’s exact test to identify associations between injury patterns, demographics (age, gender, race, ethnicity, and insurance type), and injury type (intentional or otherwise) with in-hospital mortality, applying the Benjamini-Hochberg procedure to adjust for multiplicity.

Results: 986 patients met inclusion criteria. The included cohort had a male predominance (54.2%) with a median age of 13 years (IQR 11-15 years). Intentional injury (77.6%) was the most common mechanism (Table 1). 41.9% of patients underwent neuroimaging (37.6% CT; 17.0% MRI), 52.3% underwent neck imaging (47.5% CT; 16.3% MRI), and 43.3% underwent neck arteriography specifically (41.5% CTA; MRA 2.8%). The most common injury was cerebral edema (28.1%), followed by pneumothorax (3.8%) and pulmonary edema (3.7%). Cervical spine injury occurred infrequently, with 1.9% noted to have fracture, subluxation, cord, or ligamentous injury. Neck arterial injury occurred infrequently (0.9%). Cerebral edema, pneumothorax, and pulmonary edema were each associated with in-hospital mortality (Table 2).

Conclusion: Using a large, multicenter dataset, our findings corroborate single-center research suggesting the rarity of vascular injury among pediatric hanging patients. While children in our study underwent head and neck imaging at similar rates, cerebral edema occurred more often than spine and arterial injuries. These findings underscore an opportunity to develop criteria for risk stratification of C-spine and arterial injury in pediatric survivors of hanging. Furthermore, these findings highlight an opportunity to employ pulmonary injury in survival prognostication.