Article

Reducing mortality in near-hanging patients with a novel early management protocol

a b s t r a c t

Background: Hanging is one of the most common causes of suicide world-wide, more prevalent in Developing countries. There are no established protocols for early management of near-hanging patients who present to the emergency department (ED). The use of early intubation, strict blood pressure control and targeted temper- ature management has shown promise in small studies.

Objective: To detect changes in mortality and Neurological deficits in near-hanging patients before and after im- plementation of a novel early management protocol in a tertiary care hospital in India.

Methods: Prospective cohort study conducted at a tertiary-care hospital in Tamil Nadu, India from August 2014- July 2016. For first year of study (pre-implementation), near-hanging patients were treated without a structured protocol. For second year of study (post-implementation), near-hanging patients were treated per a protocol in- cluding early intubation, strict blood pressure control and Targeted temperature management. Primary outcomes included: (1) in-hospital mortality and (2) hospital discharge without neurological deficit.

Results: 65 patients were included (27 in the pre-implementation phase and 38 in the post-implementation phase.) At presentation, there was no difference between the two groups in mean heart rate, mean arterial pres- sure, mean oxygen saturation, Glasgow coma score, or mean respiratory rate. protocol implementation decreased mortality (10/27 (37%) versus 2/38 (5%), P b 0.05) and increased the number of patients discharged without neu- rological deficit (10/27 (37%) versus 35/38 (92%), P b 0.05).

Conclusions: This novel early management protocol reduced mortality and increased the number discharged without neurological deficit in near-hanging patients in a single tertiary care center in India.

(C) 2018

Introduction

Background

Approximately 800,000 people die due to suicide every year and most suicides occur in Low- and middle-income countries [1]. Hanging is a common cause of suicide world-wide, along with poisoning and self-immolation in rural regions of India [2-4]. Suicide is more common in young adults and leads to a significant social, emotional, and

* Corresponding author at: 2120 L Street NW, Washington, D.C., 20037, United States of America.

E-mail addresses: [email protected] (H. Ijaz), [email protected]

(M. LeSaux), [email protected] (J.P. Smith), [email protected] (C. Chen), [email protected] (Y. Ma), [email protected] (A.C. Meltzer).

Economic burden on Indian society [5]. Near-hanging victims can pres- ent to the emergency department (ED) with a wide range of symptoms, from patients who are completely stable to acute respiratory failure and shock, to Anoxic brain injury [6]. Poor prognosis is associated with a Glasgow Coma Scale (GCS) b8, systolic blood pressure b90 mm Hg, Head CT imaging consistent with anoxic brain injury and hanging time longer than 5 min [7-9]. There are currently no established protocols for early management of near-hanging patients who present to the ED [10].

Importance

Early intervention and resuscitation for patients who present to the ED following near-hanging may reduce mortality and improve neuro- logical recovery [11,12]. The use of early intubation, strict blood

https://doi.org/10.1016/j.ajem.2018.08.003

0735-6757/(C) 2018

M. Tharmarajah et al. / American Journal of Emergency Medicine 36 (2018) 20502053 2051

pressure control and targeted temperature management has shown promise in small studies and relatED diseases such as cardiac ar- rest [11,13,14].

Objective

The objective of the study was to measure mortality rates in near- hanging patients before and after implementation of a novel protocol for early management in a tertiary care center in Tamil Nadu, India.

Materials and methods

Study design and setting

This prospective cohort study was conducted at the tertiary-care re- ferral center of Meenakshi Hospital in Thanjavur, India with over 200 beds, including 45 ICU beds. The study took place over two years: the pre-implementation phase occurred August 2014-July 2015 and the post-implementation phase occurred August 2015-August 2016. The study design was approved by the ethical committee in Meenakshi Hospital.

Selection of participants

Patients aged 13 and older who met the inclusion criteria defined as a “near-hanging” diagnosis were approached and consented through a family member. Patients who met the following exclusion criteria:

1) cervical spine injury; 2) carotid or vertebral artery dissection; 3) un- able to consent for study; 4) discharged against medical advice; 5) preg- nant or presumed pregnant; 6) concurrent alternate means of suicide attempt were excluded from the study.

Interventions

In the pre-implementation phase, diagnostic and management deci- sions were made by the treating physician and were not part of a struc- tured protocol. Patients were typically oxygenated using high-flow non- rebreather masks versus standard early endotracheal intubation. Hypo- tension was managed with crystalloid fluids and vasopressor medica- tions per treating physician but specific blood pressure goals were not established. No targeted temperature management protocol was available.

In the post-implementation stage, care was driven by an established protocol for early management based on three major goals: 1) early ED intubation, 2) strict control of mean arterial pressure (MAP) N65 mm Hg and, 3) targeted temperature management between 32 and 34 ?C.

The protocol was developed by a multi-disciplinary team of emer- gency physicians, intensivists, radiologists, pulmonologists, neurolo- gists, critical care nurses and patient representatives. The primary

focus of these three goals is to provide neuroprotection and reduce cy- totoxic edema. Implementation of the protocol involved several steps. First, patients who had a GCS b 9, MAP b 65 mm Hg or oxygen saturation b94% on 8 l oxygen were intubated immediately. Second, patients who had a MAP b65 mm Hg received a Central venous line, an Arterial line, and a urinary catheter. Third, near-hanging patients who met any one of the above two criteria had TTM initiated in the ICU for 24 h. TTM ini- tiation was dependent on several factors including ED- based interven- tions, bed availability, equipment availability and reconciliation of logistical factors such as registration and finances. As part of TTM, tem- perature was maintained between 32 and 34 ?C via cooling blankets with a forced air cooling machine, cold normal saline fluids, and ice packs. After 24 h of TTM, the cooling apparatus was weaned to zero over the course of 8 h. (Fig. 1) Providers were educated and protocol compliance was ensured by the presence of a protocol team member upon patient arrival to the ED.

Measurements and outcomes

Patient characteristics such as age, gender, vital signs, oxygen satura- tion, blood glucose, GCS, and temperature were recorded by research assistants at time of presentation. Patient clinical outcomes were char- acterized as: 1) survival to hospital discharge, 2) neurological deficit at hospital discharge, and 3) death. Clinical outcomes were recorded at the time of hospital discharge by Research staff. Evaluation for neurolog- ical deficits was performed at discharge by research staff by recording a Glasgow Coma Score less than fifteen, the presence of speech abnormal- ities and presences of Extremity weakness. Patients were instructed to return for follow-up five days post discharge and fifteen days post- discharge where they were seen again by research staff to confirm neu- rological status. Research staff was unblinded and trained on standard- ized neurological evaluation.

Primary data analysis

Continuous and discrete data were summarized using mean (+-stan- dard deviation) and frequency (percentage), respectively. Wilcoxon rank-sum test was used to compare continuous variables and Chi- square/Fisher’s exact test was performed to compare discrete variables. An alpha of 0.05 was used as the cutoff for significance. All analyses were performed using SAS 9.4 (SAS Institute, Cary, NC).

Results

27 patients were enrolled in the pre-implementation phase and 38 patients in the post-implementation phase. Eleven patients were ex- cluded from trial in the pre-implementation phase and six were ex- cluded in the post-implementation phase. In the pre-implementation phase, five patients were excluded for being pregnant, three patients

Fig. 1. Early management protocol for near-hanging.

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Table 1

Patient characteristics at presentation of pre/post-implementation phase.

Pre-implementation phase (n = 27)

Post-implementation phase (n = 38)

P-value

Age (Mean +- SD*)

26.85 +- 9.41

31.97 +- 11.71

0.094

Female (n (%))

14 (51.85)

22 (57.89)

0.629

Time to ED (Mean +- SD)

215.70 +- 93.04

164.16 +- 138.75

0.004

Heart rate (Mean +- SD)

49.04 +- 14.90

54.16 +- 20.02

0.293

Mean arterial pressure (Mean +- SD)

63.38 +- 27.41

79.39 +- 32.69

0.078

Respiratory rate (Mean +- SD)

19.27 +- 8.84

23.57 +- 10.32

0.124

Oxygen saturation (Mean +- SD)

83.85 +- 15.48

80.68 +- 16.92

0.419

Blood glucose (mg/dL) (Mean +- SD)

156.44 +- 70.54

158.55 +- 71.44

0.942

GCS (Mean +- SD)

7.85 +- 3.45

7.53 +- 3.45

0.762

Temperature (?F) (Mean +- SD)

96.98 +- 1.42

96.87 +- 1.88

0.663

*SD: standard deviation.

were excluded for refusal of recommended medical treatment, two pa- tients were excluded because they were in police custody and one pa- tient was excluded for a C-Spine fracture. In the post-implementation phase, four patients were excluded for pregnancy, one patient was ex- cluded due to a recent stroke and one patient was excluded for a con- comitant poisoning. TTM was initiated at 215 min on average from time of ED presentation. The time to TTM initiation was dependent on factors of resource availability. At presentation, there was no difference in the age of patient, the mean heart rate, the mean MAP, mean oxygen saturation, mean GCS and the mean respiratory rate for the pre- implementation phase and the post-implementation phase (Table 1). There was a significant difference in time to ED presentation between the pre-implementation group and the post-implementation group. The duration of ICU stay in the pre-implementation phase was

13.7 days and 10.7 days in the post-implementation phase. (Table 2) In the pre-implementation phase, ten patients (37%) died prior to hos- pital discharge. Following protocol implementation, only two patients (5%) died. In the pre-implementation phase, ten patients (37%) were discharged without neurological deficits. In the post-implementation phase, 35 patients (92%) were discharged without neurological deficits. (Table 2).

Discussion

For near-hanging patients, introduction of an early management protocol that includes early intubation, strict blood pressure control and targeted temperature management was shown to reduce mortality and increase the rate of survival without neurological deficit at hospital discharge. To our knowledge, this is the largest controlled study to ex- amine the benefits of an early management protocol for patients who survive attempted hanging.

Currently, there are no standardized protocols for management of near-hanging patients [10]. Providers focus on following the Advanced Trauma Life Support protocol and maintaining the airway via intubation and positive-pressure ventilation [10]. Resuscitation is managed via intravenous fluids. cervical spine immobilization is often utilized to prevent Spinal injury. Attention is also given to maintaining normoglycemia, and providing ventilator support [15,16]. radiographic imaging and other management decisions are performed based on the clinical presentation and suspected vascular complications from the hanging attempt. If cerebral edema is suspected, Close monitoring of

Table 2

Primary outcomes.

intracranial pressure reduction and seizure prophylaxis may be indi- cated [17].

There is no validated Clinical score to predict prognosis in near- hanging patients. The GCS is commonly used as a prognostic indicator as patients with a GCS N 12 are more likely to be discharged without neurological deficit [18]. However, in the post-implementation phase of this study, patients who presented with a low GCS still recovered with good neurological outcome. The two patients in the post- implementation group who died each had a prolonged time to initial ED presentation. Other patients presenting with a low GCS showed re- markable recovery with limited neurologic deficit. Targeted use of the protocol could improve efficiency of resource allocation in healthcare environments with a scarcity of resources.

In addition to being the largest cohort study on near-hanging pa- tients, there are several other strengths of this study. First, the patient characteristics (age, gender, heart rate, capillary blood glucose, temper- ature) of the pre/post-protocol implementation groups were similar. Second, this study was conducted in a real-world ED environment and the protocol could likely be replicated at other hospitals. Third, the highly promising results suggest that a controlled study on optimal management of near-hanging patients is warranted.

There are several limitations to this study. First, as with all studies that utilize historical (before-after) controls, the experimental and con- trol group may have been different in unmeasurable ways. There was a measureable difference in time to ED presentation in the post- implementation group which may have played an important role. There are many potential explanations for the quicker presentation, in- cluding greater awareness, earlier recognition and possibly increased utilization of resources. Pre-hospital Emergency Medical Services in this province of India are less reliable than in US and European coun- tries, and are infrequently used [19]. The overall development of Emer- gency Medicine is relatively new, so it is plausible that the existence of an organized ED at this institution could explain the quicker time to pre- sentation, or there are other unknown factors. It is unknown to what ex- tent, if at all, the factor of time to presentation was independently important in the improved outcome of patients in the post- implementation group, considering the patient groups were otherwise similar in clinical factors. Second, we did not measure the duration of hanging time in either group which is a crucial factor in determining prognosis. Third, the early management protocol was carried in ways that may have varied for some patients in the same allocation group. For example, endotracheal intubation and central line placement could have occurred in either the ED or the ICU. Finally, this study was not designed to distinguish which aspect of the early management pro- tocol was most responsible for the improvement in clinical outcomes.

Outcomes Pre-implementation phase (n = 27)

Discharge w/o neuro deficits (n (%))

10 (37.03)

35 (92.10)

b0.0001

Died (n (%))

10 (37.03)

2 (5.26)

0.006

ICU stay (days)

13.70 +- 9.64

10.68 +- 5.79

0.262

(Mean +- SD)

Post-implementation phase (n = 38)

P-value

Conclusion

Early management protocol for near-hanging patients in India was associated with an increase in both survival to hospital discharge and an increase in survival without neurological deficit. Based on the results of this trial, early endotracheal intubation, avoidance of hypotension

M. Tharmarajah et al. / American Journal of Emergency Medicine 36 (2018) 20502053 2053

and targeted temperature management should be considered in near- hanging patients. Future controlled studies are needed to confirm these findings.

Acknowledgements

The authors would like to acknowledge Jay Pandya for his help dur- ing the writing process.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.

The authors declare no conflicts of interest.

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