Abstract
Background
The pathophysiology of near-hanging in children is different from that of adults due to anatomic, physiologic, and injury-related mechanisms, with evidence suggesting that blunt cerebrovascular injuries (BCVI) and cervical spine injuries (CSI) are uncommon. We sought to estimate the incidence of secondary injuries and their association with mortality in pediatric near-hanging victims.
Methods
We performed a retrospective observational study of children (≤17 years) with a diagnosis code for hanging between October 1, 2015 and February 28, 2023 who presented to one of 47 geographically diverse US children’s hospitals. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI. We performed Fisher’s exact test with Bonferroni correction to identify associations between intentionality, sex, age, and secondary injuries with mortality.
Results
We included 1929 children, of whom 33.8% underwent neuroimaging, 45.9% underwent neck imaging, and 38.7% underwent neck angiography. The most common injury was cerebral edema (24.0%), followed by pulmonary edema (3.2%) and pneumothorax (2.8%). CSI (2.1%) and BCVI (0.9%) occurred infrequently. Cerebral edema, pneumothorax, pulmonary edema, and younger age (≤12 years) were associated with mortality.
Conclusions
In this multi-center study of pediatric near-hanging victims, BCVI and CSI occurred rarely and were not associated with mortality. While children in our study underwent neck imaging more frequently than head imaging, cerebral edema occurred more often than other injury types and imparted the highest mortality risk. Given the rarity of BCVI and CSI, a selective approach to neck imaging may be warranted in pediatric near-hanging events.
1
Introduction
Attempted hanging carries significant mortality risk and is the most common means of suicide among children under 11 years in the United States (US) [ ]. Pediatric near-hanging victims are postulated to have separate pathophysiology compared to adults and children with other blunt cerebrovascular injuries (BCVI) [ ], defined as any blunt injury to the cervical carotid or vertebral arteries. Whereas some pediatric near-hanging victims suffer cardiac arrest or significant anoxic injury, conditions that carry high risk of mortality and morbidity, others are medically stable and have good neurologic outcomes [ , ].
Emergency physicians must determine the necessity of neck imaging in both critically ill and stable pediatric near-hanging victims. There is limited evidence to guide these decisions, given that consensus-based practice guidelines to assist in the management of pediatric near-hanging do not exist. BCVI and cervical spine injuries (CSI) are thought to occur infrequently in children with a near-hanging event; several single-center studies have not reported any clinically significant cases of either injury type [ , ]. The Denver criteria, which are used to risk-stratify adults for BCVI, recommend computed tomography (CT) angiography in all near-hanging victims with anoxic injury. However, these criteria are neither specific nor sensitive in risk-stratifying children for this condition [ , ]. Given a lack of multi-center data in pediatric near-hanging events, the incidence of secondary injuries, particularly BCVI and CSI, remains unknown.
Our primary objective was to estimate the incidence of BCVI and CSI in pediatric near-hanging events, using a large multi-center sample of pediatric near-hanging victims. Our secondary objectives were to estimate the incidence of other outcomes in pediatric near-hanging events and to identify factors associated with mortality in pediatric near-hanging events.
2
Methods
2.1
Data source and inclusion
We performed a retrospective observational study of children using the Pediatric Health Information System (PHIS), an administrative database of 47 US children’s hospitals affiliated with the Children’s Hospital Association (Lenexa, KS). For the present study, we included children ≤17 years presenting between October 1, 2015 and February 28, 2023 with an International Classification of Disease, 10th revision (ICD-10) diagnosis code of asphyxiation due to hanging (T7116), with a seventh character modifier consistent with initial encounter. We excluded children with prior encounters for near-hanging in the previous 30 days and retained only the first encounter per patient. The study was designed in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines and was deemed exempt through our Institutional Review Board [ ].
2.2
Data abstraction
We extracted the following variables for each included encounter: age, race, ethnicity, sex, insurance, ICD-10 codes, mechanism, encounter type, imaging, emergency department (ED) disposition, and hospital disposition. Age was defined as patient age on hospital arrival in years. Self-identified patient race and ethnicity were included for descriptive analysis only and were merged into one composite variable with four categories: non-Hispanic White race, Hispanic/Latino ethnicity, non-Hispanic Black race, and other non-Hispanic race. Insurance type was defined as government, commercial, self-pay, or other. Mechanism was defined as accidental, intentional, assaultive, or unknown; as indicated by the sixth character modifier on the encounter ICD-10 code for asphyxiation due to hanging. Encounter types were defined as ED only, ED to inpatient, or inpatient only; with further delineation of admitted inpatients into intensive care unit (ICU) and non-ICU encounters. Imaging data were extracted using hospital billing information contained within PHIS and included the performance of neuroimaging (head CT, head magnetic resonance imaging [MRI]), neck CT and MRI, and neck CT angiography (CTA) and magnetic resonance angiography (MRA).
2.3
Outcomes
Our primary study outcomes were BCVI and CSI. Our secondary study outcomes were other secondary injuries and in-hospital mortality. We evaluated the incidence of the following secondary injuries among our sample using available ICD-10 codes: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI (cervical spine fracture, subluxation, dislocation, ligamentous injury, or spinal cord injury) ( Table 1 ). Mortality was defined for encounters by ED or in-hospital disposition of death, as well as by ICD-10 code for brain death.
| Clinical condition | ICD-10 code(s) |
|---|---|
| Anoxic injury/cerebral edema | G93.1, G93.5–6, G93.82, S06.1, S06.A1 |
| Pneumothorax | J93.9, J93.83, S27.0XXA |
| Pulmonary edema | J80, J81.0 |
| Cerebrovascular injury | I65, I77.71, I77.74, S15.0–1, S06.81–2 |
| Cervical spine injury | S12, S13.1, S13.4, S13.9, S14.0–1 |
| Brain death | G93.82 |
2.4
Statistical analysis
We described our variables, stratified by the co-occurrence of in-hospital mortality. We calculated the estimates of secondary injuries in all patients with 95% confidence intervals (CI). We described the proportion of children undergoing CT and MRI for both the complete study sample as well as the subset of patients presenting through and surviving the initial ED encounter. We performed Fisher’s exact test to identify associations between intentional mechanism, female sex, age (≤12 years), and secondary injuries with mortality. We used the Bonferroni method to adjust for multiple comparisons, thereby resulting in an alpha of 0.0063 to indicate statistical significance. We reported univariate odds ratios (ORs) with 95% CI for each category. All analyses were performed using Stata/SE 17.0. (StataCorp LLC, College Station, TX).
3
Results
We included 1929 children ( Table 2 ). The sample had a male predominance (54.3%) and a median age of 14 years (interquartile range [IQR] 12–16 years). Intentional injury (81.4%) was the most common mechanism. Mortality occurred in 20.0% of patients. Out of these, 17.4% died in or before arriving to the ED.
| Factor | Count (% of total) | ||
|---|---|---|---|
| Total | Survived | Deceased | |
| All patients | 1929 (100%) | 1543 (80.0%) | 386 (20.0%) |
| Age | |||
| 0–7 years | 173 (9.0%) | 136 (8.8%) | 37 (9.6%) |
| 8–12 years | 450 (23.3%) | 327 (21.2%) | 123 (31.9%) |
| 13–17 years | 1306 (67.7%) | 1080 (70.0%) | 226 (58.6%) |
| Race/ethnicity | |||
| White race | 1113 (57.7%) | 901 (58.4%) | 212 (54.9%) |
| Hispanic/Latino ethnicity | 291 (15.1%) | 230 (14.9%) | 61 (15.8%) |
| Black race | 348 (18.0%) | 290 (18.8%) | 58 (15.0%) |
| Other race | 177 (9.2%) | 122 (7.9%) | 55 (14.3%) |
| Sex | |||
| Female | 868 (45.0%) | 716 (46.4%) | 152 (39.4%) |
| Male | 1048 (54.3%) | 820 (53.1%) | 228 (59.1%) |
| Unknown | 13 (0.7%) | Suppressed ϕ | Suppressed ϕ |
| Insurance type | |||
| Government | 974 (50.5%) | 801 (51.9%) | 173 (44.8%) |
| Commercial | 820 (42.5%) | 660 (42.8%) | 160 (41.5%) |
| Self-Pay | 78 (4.0%) | 46 (3.0%) | 32 (8.3%) |
| Other | 57 (3.0%) | 36 (2.3%) | 21 (5.4%) |
| Injury mechanism | |||
| Accidental | 229 (11.9%) | 178 (11.5%) | 51 (13.2%) |
| Intentional | 1571 (81.4%) | 1287 (83.4%) | 284 (73.6%) |
| Undetermined | 116 (6.0%) | 66 (4.3%) | 50 (13.0%) |
| Assault | 13 (0.7%) | 12 (0.8%) | Suppressed ϕ |
| Encounter type | |||
| ED only | 728 (37.7%) | 661 (42.8%) | 67 (17.4%) |
| ED to inpatient | 923 (47.9%) | 728 (47.2%) | 195 (50.5%) |
| Inpatient only | 278 (14.4%) | 154 (10.0%) | 124 (32.1%) |
| Non-ICU admission | 625 (32.4%) | 603 (39.1%) | 22 (5.7%) |
| ICU admission | 576 (29.9%) | 279 (18.1%) | 297 (76.9%) |
| Secondary injury type | |||
| Cerebral edema | 463 (24.0%) | 158(10.2%) | 305 (79.0%) |
| Pneumothorax | 54 (2.8%) | 12 (0.8%) | 42 (10.9%) |
| Pulmonary edema | 62 (3.2%) | 21 (1.4%) | 41 (10.6%) |
| Cerebrovascular injury | 17 (0.9%) | 13 (0.8%) | Suppressed a |
| Cervical spine injury b | 40 (2.1%) | 25 (1.6%) | 15 (3.9%) |
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