Author	Affiliation
Roula Sasso, MD	American University of Beirut Medical Center, Department of Emergency Medicine, Beirut, Lebanon
Rana Bachir, MPH	American University of Beirut Medical Center, Department of Emergency Medicine, Emergency Medical Services and Prehospital Care Program, Beirut, Lebanon
Mazen El Sayed, MD, MPH	American University of Beirut Medical Center, Department of Emergency Medicine, Beirut, Lebanon; American University of Beirut Medical Center, Department of Emergency Medicine, Emergency Medical Services and Prehospital Care Program, Beirut, Lebanon

Introduction
Methods
Results
Discussion
Limitations
Conclusion

INTRODUCTION

Asphyxiation or suffocation can be defined as the deprivation of oxygen supply to body tissues and can result from mechanical or non-mechanical constriction of the airway or from a decrease in breathable gas in the respired surrounding atmosphere.¹ Suffocation and asphyxiation can vary at the forensic pathology level;¹ however, both can be used interchangeably to report a decrease in oxygen delivery to the lungs resulting in deprivation of oxygen or hypoxia.^{2, 3}

Suffocation injuries and death can result from suicidal attempt, assault or accidental injury. In parts of Europe and Asia, intentional asphyxiation by hanging is the leading manner of suicide attempts.^4,5 In the United States (U.S.), the rate of suicide by intentional asphyxiation is second only to suicide by firearms.⁶ Choking is a form of unintentional asphyxiation: choking was the third leading cause of unintentional deaths in the U.S. between 2000 and 2013 in adults aged 65 years or older⁷ and a leading cause of morbidity and mortality among children aged less than 3 years.⁸ In addition to death and multi-organ damage, complications of asphyxiation include cardiopulmonary injuries and neurological injuries, in addition to orthopedic injuries with hangings and strangulation.^9-11

The current medical literature describing suffocation injuries and clinical outcomes is limited and is mostly focused on death from asphyxiation by hanging or strangulation injuries.^12-16 Available medical literature suggests that cardiopulmonary resuscitation at the scene of suffocation injury is associated with improved clinical outcomes while longer duration of hanging is associated with increased mortality in cases of hanging asphyxiation.¹⁷ Low Glasgow Coma Scale on arrival to the emergency department (ED) has also been associated with poor clinical outcomes.¹⁸ Understanding the epidemiology of suffocation injuries, characteristics of affected victims and factors associated with mortality is important for physicians and policymakers to tailor prevention initiatives and mitigation strategies.

Our goal was to describe the characteristics of patients presenting with suffocation injuries to EDs in the U.S and to identify factors associated with mortality in this population.

METHODS

Study Design

This retrospective cross-sectional study used the 2013 public release U.S National Emergency Department Sample (NEDS). NEDS is the largest all-payer (ED) database available in the U.S. and is part of the Healthcare Utilization Project (HCUP), which is supported by the Agency of Healthcare and Research Quality.¹⁹ The NEDS database contains data from approximately 30 million ED visits each year.²⁰ In 2013, the NEDS database collected data for 134,869,015 ED visits from 947 hospitals across 30 states, representing an approximate 20% stratified sample of U.S. hospital-based EDs. The NEDS dataset is released three years after its collection.

All members of the research team who were involved in using the NEDS database completed the HCUP data use agreement training course and signed the Nationwide Data Use Agreement. The institutional review board (IRB) at the American University of Beirut provided IRB exemption for the use of the NEDS public release dataset.

We identified ED visits for patients with suffocation injury using diagnosis codes (International Classification of Disease – 9 – Clinical Modification [ICD-9-CM]) listed in Table 1. These encompassed injuries by accidental mechanical suffocation, intentional and unintentional injuries by hanging, strangulation and suffocation, injury by inhalation and aspiration of foreign bodies or food.

Population Health Research Capsule

What do we already know about this issue?

Suffocation injuries result in multi-organ damage and are a major cause of morbidity and mortality among different age groups.

What was the research question?

What are the characteristics of patients with suffocation injuries and factors associated with mortality in the United States?

What was the major finding of the study?

Mortality from suffocation is high with a significant burden on younger individuals and those with intentional injuries

How does this improve population health?

Familiarity with patients at risk of suffocation injuries can improve clinical outcomes and allow for implementation of initiatives that target behavior changes in this population.

Variables available from the NEDS database included patient characteristics and comorbidities, type of injury and injury intent, patient disposition, admission rates, hospital length of stay and cost. Clinical outcome was defined as mortality in ED or during hospital stay (yes/no).

Statistical Analysis

We performed statistical analysis with SPSS (version 24) statistic software package. The description of the sociodemographic, clinical and administrative characteristics was presented as frequencies, percentages, and 95% confidence interval (CI) for the categorical variables and mean and 95% CI for the continuous variables. We used the Rao-Scott chi-square test for complex sample design to determine the significance of the statistical association between the independent variables and mortality (yes/no), the dependent variable. All variables that were found to be statistically significant in the bivariate level were included in a logistic regression model to determine the factors significantly associated with mortality. We presented results of the multivariate analysis as odds ratio (OR) along with the corresponding 95% CI. Convenient methods including CSDESCRIPTIVES, CSTABULATE, and CSLOGISTIC for complex survey design were performed to calculate accurate estimates. A value was considered statistically significant at a p-value less than or equal to 0.05.

RESULTS

We included a total of 27,381 ED visits for suffocation injuries in the study. The resulting incidence for suffocation injuries in 2013 in the U.S. was 20 per 100,000 ED visits. Inhalation and ingestion of food causing obstruction of respiratory tract or suffocation was the most common presentation (51.6%), followed by suicide and self-inflicted injury by hanging, strangulation, and suffocation (39.3%) (Table 1).

Over half of the patients (54.7%, 95% CI [53.5 – 55.9]) were between 19–65 years. Males (59.1%, 95% CI [57.9 – 60.2]) were more common than females, and most patients had chronic conditions (72.8%, 95% CI [71.8 – 73.9]). The most common body system indicators (defined as a collective designation of body system specific ICD-9-CM codes) were injury and poisoning (80.2%, 95% CI [79.2 – 81.1]) and mental disorders (47.4%, 95% CI [46.2 – 48.5]). The majority of patients had reported injuries on presentation (80.3%, 95% CI [79.4 – 81.2]) and the most common reported method of injury was injury by assault (3.4%, 95% CI [3.0–3.9]) followed by injury by poisoning (2.0%, 95% CI [1.7–2.3]). Patients had mainly minor injuries (Injury Severity Score <15) (99.5%, 95% CI [99.3 – 99.7]). Intentional self-harm was recorded in 40.1% (95% CI [38.9 – 41.2]) of cases with injuries. ED suffocation related visits were similar across all seasons. Most visits (71.9%, 95% CI [70.8 – 72.9]) were during weekdays and Medicare was the most common type of coverage (29.3%, 95% CI [28.3 – 30.0]) (Table 2).

Most patients were either treated and released from the ED (54.9%, 95% CI [53.8 – 56.1]) or admitted to the same hospital as presentation (33.6%, 95% CI [32.6 – 34.7]). Patients who were admitted had an average length of stay of 6.2 days (95% CI [5.8– 6.7]). Overall mortality in the study population was 10.9% (95% CI [10.2 – 11.7]). Mortality rates ranged from 9.6% (95% CI [8.6 – 10.8]) for patients with “suicide and self-inflicted injury by hanging strangulation and suffocation” to 30.7% (95% CI [22.5 – 40.4]) for patients with “hanging, strangulation, or suffocation, undetermined whether accidentally or purposely inflicted.” Those with accidental mechanical suffocation had a mortality rate of 11% (95% CI [10.0–12.0]). The mean for total ED charges was $3,620.20 (95% CI [3531.6 – 3708.7]) (Table 3).

We performed a bivariate analysis (not shown) to compare patients’ characteristics by outcome (mortality); significant differences were noted between the two groups. Patients who died were more likely to be older, have chronic conditions and be of male gender. They also had more admissions during weekends and had more injuries reported. Higher frequencies of mental health disorders, of intentional self-harm, injury by poisoning and injury by assault were, however, noted in the group of patients who survived. There was no difference in patient outcomes by season of admission or by injury severity.

In the multivariate analysis, factors that were significantly associated with increased mortality after suffocation (Table 4) included male gender (OR [1.3], 95% CI [1.1–1.6]), disease of the circulatory system (OR [11.6], 95% CI [8.9–15.1]), diseases of the nervous system (OR [3.0], 95% CI [2.4–3.8]), diseases of the respiratory system (OR[1.9], 95% CI [1.6–2.4]) and diseases of the genitourinary system (OR [1.5], 95% CI [1.1–1.9]). Additional factors that were also associated with increased mortality included age category 4–18 years (OR [1.8], 95% CI [1.2–2.7]), intentional self-harm (OR [2.0], 95% CI [1.5–2.7]) and having one or no injury reported (OR [1.5], 95% CI [1.1–2.0]). Mental health disorders (OR [0.4], 95% CI [0.3–0.5]) were found to be negatively associated with mortality.

DISCUSSION

This study examined suffocation injuries in a large national sample of ED visits; it is the largest study to date to report on this medical condition and to attempt to identify its burden using a national sample in the U.S. While the mechanisms of injury resulting in suffocation and asphyxiation are numerous, several forms of asphyxiation are uncommon and under-reported. This is evident in the medical literature with several forms of asphyxiation described only in case reports or case series.^{21, 22}.Some studies have reported mortality rates in more common forms of suffocation injuries such as hanging and strangulation.^{10,17,18,23,24} Our study, however, addressed all forms of suffocation injuries using a national sample, in an attempt to identify the burden of this disease and avoid overlooking under-reported and uncommon forms of injury that result in suffocation and asphyxiation.

The incidence of suffocation injury in 2013 among ED patients was 20 per 100,000 individuals, and the mortality rate was 10.9% (95%CI [10.1–11.7]) with varying mortality rates, ranging from 9.6% (suicide and self-inflicted injury by hanging, strangulation, and suffocation) to 30.7% (undetermined if self-inflicted or accidental). A study in Japan showed a 77% mortality rate in individuals presenting with suicidal-intent hanging injury,¹⁷ whereas another study in Australia showed a mortality rate of 12% for the same form of injury.¹⁸ This discrepancy in mortality rates could be attributed to different factors including lack of standardized management of suffocation injuries,^25-27 higher injury acuity, or different groups of patients included in other studies.

Additionally, 47.4% of patients in this study had a mental health condition and 40.1% had intentional injury reported. These results are in line with previous studies suggesting that suffocation injuries are commonly a result of intentional self-harm or suicidal attempt and are likely to occur in patients with a history of psychiatric disorders.²³ In fact, a previous study examining deaths in adolescents due to hanging injury revealed that the majority of hangings (98.4%) were the result of a suicidal attempt.²⁸ Similarly, deaths due to plastic-bag suffocation were mostly in adults and resulted from suicidal attempts.²² Our results also showed that intentional self-harm was associated with higher odds of mortality after controlling for confounding factors in the multivariate analysis. While the literature assessing the impact of intentional injury on mortality in patients with suffocation injuries is scarce, studies exploring this impact in injury/trauma patients in general have reported higher mortality associated with intentional injury.^{30, 31}

Males were both more likely to present with and die from suffocation injuries. The available published literature reports conflicting data on the gender role in suffocation injuries by hanging.^{12,17,18,23,26} by inhalation of helium gas,^6,32, by plastic-bag suffocation,²² and by autoerotic asphyxiation.²¹ The various mechanisms of suffocation may have contributed to this inconsistency in impact of gender on outcomes after suffocation. Other confounding factors such as intentional injury may also explain this inconsistency. Several studies have suggested that suffocation related to suicidal intent is more common in males,^9,32,33-35 while suffocation related to assault or homicidal intent is more likely to occur in females.^5,36,37.

Patients aged 4–18 years were observed to have higher odds of mortality compared to other age groups. The existing literature does not provide clear evidence for this. However, some studies suggest that children are more vulnerable to have complete airway obstruction and are more prone to delayed airway edema after strangulation, due to the relatively small size of the airway.^{38, 39} Additionally, we can speculate that children are more likely than adults to experience prolonged unintentional suffocation as they are often left unattended and incapable of self-help. More research investigating the relationship between age and mortality among patients with suffocation injuries could help develop age-specific prevention strategies.

This study also showed that individuals with disease of the circulatory system, nervous system, respiratory system and genitourinary systems are significantly more likely to die from suffocation injuries. This was expected since patients with baseline cardiac, respiratory and kidney diseases are more likely to have poorer clinical outcomes.^40-42 Mental disorders seemed to be negatively associated with mortality in patients presenting with suffocation injuries. While mental disorders are associated with higher natural and unnatural cause mortality,⁴³ some studies have demonstrated mental disorders to be protective in trauma patients.^44,45 Individual with suffocation injuries who survive are more likely to undergo psychiatric disease evaluation and to get diagnosed in the ED and in hospital with a psychiatric disorder, which may result in a higher frequency of mental disorders in surviving patients. Additionally, patients could suffer from psychiatric disorders that are a result of the traumatic injury experienced. However, further studies are needed to evaluate the effect of pre-existing mental disorders on patients with suffocation injuries.

LIMITATIONS

This study has limitations inherent to its retrospective nature. NEDS is, however, a large U.S. national database of ED visits and the study results can be generalized to other patients presenting with suffocation injuries in the U.S. or in other developed settings. The data was obtained from the NEDS database using ICD-9-CM codes for suffocation diagnosis. There could be an underestimation of the actual suffocation injury rates due to variations in coding in the 947 hospitals included in the database. It is also possible that many patients who died as a result of suffocation might not have been transported to the ED and therefore were not included in this study, which could potentially have led to underestimation of mortality rate of asphyxiation. The NEDS database is de-identified, so we could not identify patients with suffocation injury readmissions. Considering that a high percentage of patients had mental disorders or a history of injury and poisoning, it is likely that the number of readmissions in our selected population is significant. Other studies excluding readmissions might identify other factors associated with mortality in patients with suffocation injury. Patients presenting with a recurrent suffocation injury are also more likely to have poorer prognosis than those presenting with a suffocation injury for the first time.

This study included patients with suffocation from different mechanisms. Even though mortality rates were reported for different mechanisms when possible, restrictions related to availability of clinical variables limited our ability to draw more specific recommendations about clinical management or to identify whether the associated clinical conditions were co-morbid conditions or arose as a result of the asphyxiation.

CONCLUSION

Mortality from suffocation injuries remains high in the U.S with a significant burden on children and adolescents and on patients with intentional injuries. Familiarity with the characteristics of patients at risk of suffocation injuries and with factors associated with increased mortality after such injuries is important to help improve clinical outcomes. Additionally, tailored initiatives implementing behavior and environment change and targeting populations at risk of suffocation injuries are needed.

Footnotes

Section Editor: John Ashurst, DO

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Mazen El Sayed, MD, MPH, American University of Beirut Medical Center, Department of Emergency Medicine, 11-0236 Riad El Solh, Beirut, Lebanon 1107 2020. Email: melsayed@aub.edu.lb. 7 / 2018; 19:707 – 714

Submission history: Revision received December 4, 2017; Submitted March 30, 2018; Accepted April 18, 2018

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

REFERENCES

1. Sauvageau A, Boghossian E. Classification of asphyxia: the need for standardization. J Forensic Sci. 2010;55(5):1259-67.

2. Saukko P, Knight B. Suffocation and ‘asphyxia’. Knight’s Forensic Pathology. 2004:352-67.

3. Boghossian E, Tambuscio S, Sauvageau A. Nonchemical suffocation deaths in forensic setting: a 6-year retrospective study of environmental suffocation, smothering, choking, and traumatic/positional asphyxia. J Forensic Sci. 2010;55(3):646-51.

4. Helaly AMN, Ali EF, Zidan EM. The pattern of suicide in the Western Kingdom of Saudi Arabia: a retrospective study from 2008 to 2012. Am J Forensic Med Pathol. 2015;36(1):27-30.

5. Van den Hondel KE, Buster M, Reijnders UJL. Suicide by asphyxiation with or without helium inhalation in the region of Amsterdam (2005–2014). J Forensic Leg Med. 2016;44:24-26.

6. Suicide and Self-Inflicted Injury. 2014. Available at: https://www.cdc.gov/nchs/fastats/suicide.htm. Accessed August 31, 2017.

7. Kramarow E, Chen L-H, Hedegaard H, et al. Deaths from unintentional injury among adults aged 65 and over: United States, 2000–2013. NCHS data brief. 2015:199.

8. Policy Statement–Prevention of Choking Among Children. Pediatrics. 2010;125(3):601-7.

9. Suarez-Penaranda JM, Alvarez T, Miguens X, et al. Characterization of lesions in hanging deaths. J Forensic Sci. 2008;53(3):720-3.

10. Mansoor S, Afshar M, Barrett M, et al. Acute respiratory distress syndrome and outcomes after near-hanging. Am J Emerg Med. 2015;33(3):359-62.

11. Shin J, Lee H, Kim J, et al. Outcomes of hanging-induced cardiac arrest patients who underwent therapeutic hypothermia: a multicenter retrospective cohort study. Resuscitation. 2014;85(8):1047-51.

12. Russo MC, Verzeletti A, Piras M, et al. Hanging deaths: a retrospective study regarding 260 cases. Am J Forensic Med Pathol. 2016;37(3):141-5.

13. Gandhi R, Taneja N, Mazumder P. Near hanging: Early intervention can save lives. Indian J Anaesth. 2011;55(4):388-91.

14. Wee JH, Park KN, Oh SH, et al. Outcome analysis of cardiac arrest due to hanging injury. Am J Emerg Med. ;30(5):690-4.

15. Ma J, Jing H, Zeng Y, et al. Retrospective analysis of 319 hanging and strangulation cases between 2001 and 2014 in Shanghai. J Forensic Leg Med. 2016;42:19-24.

16. Kim MJ, Yoon YS, Park JM, et al. Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study. Am J Emerg Med. 2016;34(8):1467-72.

17. Matsuyama T, Okuchi K, Seki T, et al. Prognostic factors in hanging injuries. Am J Emerg Med. ;22(3):207-10.

18. Penney DJ, Stewart AHL, Parr MJA. Prognostic outcome indicators following hanging injuries. Resuscitation. 2002;54(1):27-9.

19. Overview of HCUP. Available at: https://www.hcup-us.ahrq.gov/overview.jsp. Accessed August 28, 2017.

20. Overview of the Nationwide Emergency Department Sample (NEDS). Available at: https://www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed August 28, 2017.

21. Janssen W, Koops E, Anders S, et al. Forensic aspects of 40 accidental autoerotic deaths in Northern Germany. Forensic Sci Int. 2005;147:S61-4.

22. Crudele GDL, Di Candia D, Gentile G, et al. One hundred and one cases of plastic bag suffocation in the Milan area between 1993 and 2013 – correlations, circumstances, pathological and forensic evidences and literature review. J Forensic Sci. 2016;61(2):361-6.

23. Wee JH, Park JH, Choi SP, et al. Outcomes of patients admitted for hanging injuries with decreased consciousness but without cardiac arrest. Am J Emerg Med. ;31(12):1666-70.

24. Hsu CH, Haac B, McQuillan KA, et al. Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2017;82(2):387-91.

25. Berg RA. Role of mouth-to-mouth rescue breathing in bystander cardiopulmonary resuscitation for asphyxial cardiac arrest. Crit Care Med. 2000;28(11 Suppl):N193-5.

26. Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging—A retrospective analysis. Resuscitation. 2009;80(2):210-2.

27. Mercier E, Roberts G. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Therapeutic hypothermia for cardiac arrest of asphyxial origin. Emerg Med J. 2013;30(8):689-90.

28. Bhosle SH, Zanjad NP, Dake MD, et al. Deaths due to hanging among adolescents – a 10-year retrospective study. J Forensic Leg Med. 2015;29:30-3.

29. Davison A, Marshall TK. Hanging in Northern Ireland—a survey. Med Sci Law. 1986;26(1):23-8.

30. Niemcryk SJ, Hines R, Brawley M, et al. Intentional and unintentional injury in the State of Nevada: 1989–1992. Am J Prev Med. 1998;14(1):43-53.

31. Bennett KM, Vaslef SN, Shapiro ML, Brooks , et al. Does intent matter? The medical and societal burden of self-inflicted injury. J Trauma. 2009;67(4):841-6.

32. Austin A, Winskog C, van den Heuvel C, et al. Recent trends in suicides utilizing helium. J Forensic Sci. 2011;56(3):649-51.

33. Abd-Elwahab Hassan D, Ghaleb SS, Kotb H, et al. Suicidal hanging in Kuwait: retrospective analysis of cases from 2010 to 2012. J Forensic Leg Med. 2013;20(8):1118-21.

34. Kanchan T, Menezes RG. Suicidal hanging in Manipal, South India – victim profile and gender differences. J Forensic Leg Med. 2008;15(8):493-6.

35. Dean DE, Kohler LJ, Sterbenz GC, et al. Observed characteristics of suicidal hangings: an 11-year retrospective review. J Forensic Sci. 2012;57(5):1226-30.

36. Zahid HK, Muhammad A, Zia Ul Islam Khan Muhammad, et al. Asphyxial deaths: a four-year retrospective study In Peshawar. J Postgrad Med Inst. 2014;28(1).

37. Vij A, Menon A, Menezes RG, et al. A retrospective review of homicides in Mangalore, South India. J Forensic Leg Med. 2010;17(6):312-5.

38. Stevens R, Lane G, Milkovich S, et al. Prevention of accidental childhood strangulation, a clinical study. Ann Otol Rhinol Laryngol. 2000;109(9):797-802.

39. Hackett A, Kitsko D. Evaluation and management of pediatric near-hanging injury. Int J Pediatr Otorhinolaryngol. 2013;77(11):1899-901.

40. Andrew E, Nehme Z, Bernard S, et al. The influence of comorbidity on survival and long-term outcomes after out-of-hospital cardiac arrest. Resuscitation. ;110:42-7.

41. Carew HT, Zhang W, Rea TD. Chronic health conditions and survival after out-of-hospital ventricular fibrillation cardiac arrest. Heart. 2007;93(6):728-31.

42. Søholm H, Hassager C, Lippert F, et al. Factors associated with successful resuscitation after out-of-hospital cardiac arrest and temporal trends in survival and comorbidity. Ann Emerg Med. 2015;65(5):523-31.e2.

43. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72(4):334-41.

44. Morris JA, MacKenzie EJ, Edelstein SL. The effect of preexisting conditions on mortality in trauma patients. JAMA. 1990;263(14):1942-6.

45. Shoko T, Shiraishi A, Kaji M, et al. Effect of pre-existing medical conditions on in-hospital mortality: analysis of 20,257 trauma patients in Japan. J Am Coll Surg. 2010;211(3):338-46.