Hanging has been known as a significant method of suicide due to its high completion rate. The purpose of this study was to analyze the factors that influence the outcome of hanging, by comparing the actual clinical course with the pathophysiology of hanging derived from laboratory experiments. [Patients and methods] Of 411 with suicide attempt during the period from April 1998 through August 2003, 44 hangings were examined. With respect to the completion rate of suicide, we compared hanging with other methods. We divided the hangings into 2 groups by presentation of cardiopulmonary arrest (CPA) upon arrival of emergency medical technician (EMT), and compared the clinical course and the outcome of these 2 groups. Moreover, we divided the non-CPA group into 2 subgroups in accordance with severity of consciousness impairment on admission, and compared average age, gender, the type of hanging, mortality rate, rehabilitation rate, and the incidence of delayed postanoxic encephalopathy. Finally to analyze prognostic factors in hanging, all 44 patients were examined for factors such as age, gender, the type of hanging, and the presence of CPA. [Results] Hanging patients accounted for 10.7% of the patients with suicide attempt, and the completion rate of hanging was the highest (75%) in others. Of these hangings, CPA upon arrival of ELST accounted for 33, Of these hangings of CPA, 7 were resuscitated. However, 6 resulted in death and only 1 could be rehabilitated. On the other hand, of 11 hangings of non-CPA, 1 died and the other 10 could be all rehabilitated. In 2 subgroups of these 11, we revealed no significant differences in background, clinical course and outcome. In a prognostic study of the 44 hangings, only the presence of CPA showed significant differences between survivors and non-survivors. [Discussion] It has been reported that death by hanging is mostly caused by asphyxia. In most cases of asphyxia, cardiac arrest occurs following higher cortical dysfunction, so the outcome of these cases being presented with CPA was often miserable. Only the presence of CPA was the significant factor affecting outcome. On the other hand, in cases which present autonomic reflex actions, higher cortical dysfunction occurs following cardiac arrest. Therefore, we consider that a case falling into CPA through autonomic reflex actions is likely to be saved after urgent resuscitation. [Conclusions] With respect to the treatment of hanging, we must consider treatment with discreet ness as the outcome is often miserable, especially following CPA.

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Emergency surgeries were conducted with the aid of a mixed type coagulation factor preparation on 2 patients who developed peritonitis while under oral medication with warfarin. The first case, an 80-year-male, had been treated with 2mg/day of oral warfarin following aortic valvoplasty and prosthetic vascular replacement. He underwent surgery for perforating appendicitis and peritoneal abscess. Prior to the surgical procedure, his PT (INR) was 4.69 and Thrombotest, below 5%. The second case, an 89-year-old woman, had been treated with 1.5mg/day of oral warfarin for atrial fibrillation. She underwent surgery with a diagnosis of strangulating ileus. Her preoperative PT (INR) was 2.73 and Thrombotest, 5.2%. To these two patients, 500E of a prothrombin complex concentrates (PCC) was administered prior to surgery. The coagulation test that was conducted on these patients 15 minutes after this treatment showed a marked shortening in the coagulation time in the PT (INR) and Thrombotest. Their pen-operative courses were uneventful, without hemorrhagic tendencies or complications. The use of a mixed coagulation factor preparation is not included in the current coverage under our National Health Insurance Policy when it is applied to patients who had been receiving warfarin and undergoing emergency surgery. However, the efficacy of the preparation was indicated in these cases. An evaluation is needed to see if the current coverage under this insurance policy should be extended to include this modification.

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We report a very rare case of “Takotsubo” cardiomyopathy caused by hanging. A 36-year-old woman with depression was admitted to our hospital in an unconsciousness state. She had taken a lot of narcoleptics and had drunk excessive alcohol. Her mother found her hanging with an electric cord around her neck. Her vital signs showed a blood pressure of 62/52mmHg, a pulse rate of 132beats/min and a temperature of 35.4°C. Her unconsciousness level was measured at III-300 on the Japan Coma Scale (JCS). A chest X-ray showed severe pulmonary edema. The echocardiogram showed severe hypokinesis around the left ventricular, similar to “Takotsubo.” We applied an IABP because we could not maintain her blood pressure with catecholamine. Gradually her heart's wall motion improved and pulmonary edema was reduced. She was weaned from IABP on the third day. The left ventriculograms revealed “Takotsubo” like symptoms. The coronary angiography showed normal coronary arteries. The patient was discharged from our hospital on the 12th day. In this case, the serum concentration of catecholamine at the acute phase was high. It is thought that cardiomyopathy is caused by a rise in the catecholamine blood level. To the best of our knowledge, this is the first report of “Takotsubo” cardiomyopathy caused by hanging.

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We presented 8 patients who “talked and died” with head trauma and reported a representative case and clinical features of each cases. A patient of “talk and die” is defined as a patient who talks on admission after trauma, and subsequently shows a rapid neurological deterioration and death. On admission most could talk but were not alert, all 8 patients developed rapid neurological deterioration within 22.5h after trauma. Prior to rapid neurological deterioration, despite initial preserved consciousness, these patients characteristically showed a variety of CT abnormalities. In a patient of “talk and die”, rapid neurological deterioration occurs after trauma, and is caused by enlargement of the lesion occupying the intracranial space, associated with focal masses such as subdural hematoma and intracerebral hematoma, ischemia of the surrounding tissue, brain swelling, edema and axonal injury e.t.c, but they are controversial. To salvage a patient who talks and die, speedy transport to the appropriate hospital, careful observation and repeated CT after trauma should be performed in patients who are basically awake but confused, showing skull fracture and various CT abnormalities. Finally, recognition of “talk and die” is crucial to preventing this pathogenesis.

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An 89-year-old man, who was under observation for a several-week history of a small amount of melena, was referred to our hospital when he developed abdominal pain and nausea of sudden onset. Physical examination revealed subcutaneous emphysema extending from the cervical to the femoral region, more pronounced on the left side of the body. The abdomen was distended and there were signs of tenderness and peritoneal irritation over the entire abdomen. A plain x-ray of the abdomen revealed a markedly dilated sigmoid colon. Based on a suspicion of volvulus of the sigmoid colon, emergency operation was conducted. The sigmoid colon was found to be markedly emphysematous, however, there was no evidence of volvulus or perforation to the peritoneal cavity. Examination of specimens collected at surgery revealed a deep ulcer in the sigmoid colon, extending up to the subserosal layer. These observations suggest that the pressure in the intestinal tract was probably elevated because of occlusive ileus due to a hard scatoma (stools) and that the gas from the lumen diffused through the ulceration to the subserosal layer, and then on to the subcutaneous tissue. The present case was thus considered to show a very uncommon presentation.

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