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So now we are going to have a little bit of a look at ligature injuries and how we deal with them. Again, we need to remember that safety always comes first. And for somebody to actually have a ligature injury, there are two most common causes. One is self-harm or whether they have been hung and we need to know the difference between the two. It is not us as medics to make that decision. That is a police call. That is a forensic call. But what forensics require is actual evidence to prove one way or another.

So what we got to look at when we arrive at the scene first of all is, is this patient viable or non-viable. In other words, can we actually do something for this patient to actively try and resuscitate them or are they long past that? And if they are long past it, things like rigour mortis where all the joints tighten up and the patient become stiff, pooling of the blood, colouration where the blood starts to pool into the lower limbs, cold to the touch, these sort of things. So if the patient is past help, in other words, no matter what we do, we will never get this patient back, we shouldn't attempt anything. This is now a crime scene. The police need to see this scene exactly as it is. So we do not want to contaminate anything. We do not want to touch anything. We do not want to cut them down. We leave them exactly where they are. It is now not our problem anymore. It is now scenes of crime. It is a police investigation.

However, if the patient is viable and there is something that we deem that we can do, then we have to act appropriately. We do need to bring the patient down to the ground. We do need to take the patient off the ligature. Because while the ligature is in place, it will be blocking off the airway, it'll be tightening up and occluding the airway, it will be creating problems with the spinal cord and everything else. What we have got to remember is spinal cord injuries at this point are probably highly likely. However, they are not really our first priority. Our first priority is resuscitation. The spinal injury comes second.

We cut the patient down and we need to cut the rope at a decent length leaving the ligature in place, leaving the knot in place. Do not try to undo the knot. The police will want to see the knot again to see whether the person tied it themselves or whether it was tied by somebody else. So we cut the rope leaving the ligature in place and then we try and cut the rope itself, so as we can leave the knot intact. If you cannot avoid that, then you will do whatever it takes. Priority number one is the patient, not the forensic's outcome. But if we can, we want to try and leave everything as much as we can intact for the police investigation. But remember, a patient comes first, investigation come second.

So take the weight off the patient, undo the knot, cut the knot, but get the ligature away from the patient's neck and throw it as quick as you possibly can. Bring the patient down into a position where we can now start to work. And our priorities now are opening the airway, listening for 10 seconds, looking to see whether there is any breathing. And if there is not, commencing resuscitation, which we will look at in a separate video.

But signs and symptoms, bruising around the neck, pooling of blood at the extremities, pooling of blood in the head. What a ligature actually tries to do, a hanged man's ligature, it is there to try and break the spinal cord. So if the fall is far enough and the ligature tightens correctly, then it actually snaps the axis of the spinal cord where it joins to the skull. And when that axis breaks, it cuts the spinal cord in half and the patient dies instantly. If it has been effective, if it has been efficient, the patient that has hung themselves will be fatal. There is nothing we can do for it. But a lot of people will do this, do not understand the technique, they will put the rope too long so they hit the floor and break their ankles and then stuck, they cannot put any weight to take the ligature off themselves, so you might find them in a distressed situation. But airway problem is the biggest killer of that patient.

You also might find they use ropes or towels or blankets, all sorts of stuff, whatever they can get their hands on that do not tighten properly. They tighten enough to occlude the airway to a degree so they cannot breathe properly. But they do not actually snap the spinal cord, break the actual spinal cord itself so the patient now is choking, suffocating due to the tightness around the throat. And again, this needs to be removed as fast as we possibly can. If we do not get it off quick, it will be a very painful, very slow death basically because they will not be able to get enough air to breathe properly and with brain damage and all the ongoing problems from that.

So in short, if they have hung themselves and we deem that the patient is a potential salvageable patient, we get them down as fast as possible, we open the airway, we start to work. We basically are either going to cardiac arrest or airway management mode. Remember fluids, remember swelling, remember the actual pressure that has been created may well break things like the airway itself, it may get punctured, it may get torn. There are masses and masses of potential problems with ligature injuries. But the key is, the faster we can get the patient down, the ligature off and the airway opens back up, the better the outcome is going to be.

Safety comes number one. So remember, you may not be able to hold the patient yourself and cut the ligatures down. You really need to have other people out to give you a hand. But the faster they are of that, the hanging position, the faster that ligature is removed from around the neck, the better the outcome is gonna be. But also, as I said, when we first started, do not remove, do not cut ligatures down when the patient is deceased and not for resuscitation due to the length of time they have been there because the police need that for their investigations, their scenes of crime.

If we take a short close look at the spine itself, 3 to 5, the C-spine here, keep the diaphragm alive. So if we actually sever our spine between 3 and 5, you cannot breathe on your own. That is where the nerves run down, they operate the diaphragm and keep you breathing. The area that a ligature is designed to snap is the axis which is the top; the very, very top that keeps the skull intact. And if we actually snap the axis, we will sever the vertebrae itself. We will sever the spinal cord and that is instantly fatal. If it is not done up tight enough or it does not work efficiently, you have got to remember there are two pipes coming down from the throat, from the mouth and the airway, one containing air, one goes to the stomach, and they get compressed. So if you imagine you have got two pipes at the front and the spinal cord being solid, as the rope tightens, it cuts off the two pipes, one being the oesophagus, one being the larynx taking air down. And that will cut off the air supply to the lungs which cut off the air supply to the body and the patient will die from it.

So two things happen: Either the spinal cord itself separates and dies instantly, 3 to 5 damage there, stops your breathing, or you crush the trachea and oesophagus and breathing will stop from that point.