Background
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] :
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Finger marks around the neck
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Bruising
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Coughing
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Stridor
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Change in voice
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Facial/subconjuctival petechiae
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Facial plethora
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Laryngeal tenderness [4]
Evidence of hanging includes the following [5, 6, 7, 3] :
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Ligature marks around the neck
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Use of a belt, rope, or cord
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Facial/subconjuctival petechiae
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Retinal/scleral hemorrhage
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Stridor
Pathophysiology
Adult
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.
Pedatric
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.
Epidemiology
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%.
Prognosis
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.
Patient Education
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.
