Initial assessment (ABCDE) (Airway patency, breathing, circulation, disability (GCS, pupils), exposure — document mechanism: complete vs partial hanging, ligature type/material, height of drop, estimated duration of hypoxia, resuscitation at scene (AAP, ERC, AHA PALS, ATLS pediatric trauma))
Mechanism & safeguarding (Distinguish intentional self-harm vs accidental — psychiatric evaluation and safeguarding referral for deliberate acts; document ligature marks, facial petechiae, voice changes, dysphagia/odynophagia; GCS serially, focal motor deficits (AAP, pediatric trauma guidelines))
First-line therapy
Oxygen • inhaled
Duration: PRN · Start if SpO₂ <94% or respiratory distress — nasal cannula or mask; target SpO₂ ≥94%; wean when stable on room air (AHA, ERC, AAP)
• **Observation period:** minimum **24 h** inpatient monitoring; many pediatric hanging protocols recommend **24–48 h** before discharge even if initially asymptomatic — delayed airway edema and neurologic deterioration are well described (AAP, pediatric trauma guidelines).
• **Serial assessments q2–4 h:** GCS, pupils, voice/hoarseness, stridor, swallowing, work of breathing, SpO₂, RR, heart rate, blood pressure; document ligature marks and petechiae distribution (above/below clavicles) (AAP, ERC).
• **Cervical spine:** maintain C-spine precautions if fall/jump component, trauma mechanism, neck pain, neurologic deficit, or unreliable examination; low-energy hanging without fall — selective immobilization per ATLS/pediatric trauma — many protocols immobilize initially then clear clinically (ATLS, pediatric trauma guidelines).
• **Supplemental O₂:** initiate if SpO₂ **<94%** or respiratory distress — wean when stable on room air sustained (AHA, ERC).
• **Escalate immediately** if any symptom develops: voice change, dysphagia, vomiting, cough, abnormal neuro exam, petechiae above clavicles with symptoms, tachypnea, or declining GCS → switch to symptomatic pathway and admit for active management (AAP, pediatric trauma).
Escalate to symptomatic pathway • procedure
Duration: Immediate · Any new symptom during observation → active airway management, imaging as indicated, ward/PICU admission — do not discharge (AAP, pediatric trauma, ERC)
• **Admit (not observation-only):** voice change, dysphagia, vomiting, cough, abnormal neuro exam, petechiae above clavicles with symptoms, ligature mark with symptoms, abnormal SpO₂, tachypnea, GCS <15, significant mechanism, or intentional self-harm needing psych evaluation (AAP, pediatric trauma).
• **Imaging during observation:** CXR if respiratory symptoms develop; CT head if altered mental status or seizure; CT neck/angio if vascular injury signs (Horner syndrome, unilateral weakness, pulse deficit, severe headache) — see symptomatic variant (AAP, ATLS).
• **Psychiatric/safeguarding:** intentional self-harm requires psychiatry and safeguarding clearance **before discharge** — involve child protection services per local policy; do not discharge to unsafe environment (AAP, pediatric mental health guidelines).
• **Discharge criteria:** asymptomatic throughout **minimum 24 h** (prefer 24–48 h per protocol); normal serial neuro, respiratory, and airway exams; normal SpO₂ on room air; psychiatric/safeguarding clearance for intentional cases; reliable caregivers with return precautions (AAP, pediatric trauma).
• ABCDE on arrival: document mechanism (complete vs partial hanging, ligature type, drop height, hypoxia duration); assess ligature marks, facial petechiae, voice, swallowing; GCS and pupils serially; intentional vs accidental — activate safeguarding/psychiatry pathway for deliberate acts (AAP, ATLS, pediatric trauma).
• C-spine: immobilize if fall/jump, trauma mechanism, neck pain, neuro deficit, or unreliable exam; low-energy hanging without fall — selective approach per ATLS/pediatric trauma — document clinical rationale; many protocols immobilize initially (ATLS, pediatric trauma guidelines).
• Observation: minimum **24 h** inpatient (many protocols **24–48 h**) with serial SpO₂, RR, GCS, airway/voice exam q2–4 h — delayed laryngeal edema and anoxic brain injury can occur hours after event (AAP, ERC, pediatric trauma consensus).
• Discharge: only if asymptomatic entire observation period, normal room-air SpO₂, normal serial neuro and airway exams, psychiatric/safeguarding clearance for intentional cases — return precautions for delayed airway edema, neuro changes, swallowing difficulty (AAP).
• Safeguarding: near hanging in children requires sensitive assessment — involve psychiatry, social work, and child protection per local policy; clinical tone supportive; ensure safe disposition before discharge (AAP, pediatric mental health guidelines).
