A 15-year-old-male complaining of a headache (HA) is brought to the emergency department by his parents. They report that he has had a diffuse HA intermittently over the past few months. The HA is described as a “pressure” and tends to occur in the late afternoon after school and early evening. It is not associated with nausea, vomiting, vision changes, or neurological symptoms. There is no significant past medical, surgical, family, or social history. On physical exam, his vital signs and neurological examination are normal. You notice faint petechiae around his orbits bilaterally. You ask him to remove his hoodie, and you notice an interesting finding on his neck (see Figure 1). What is the diagnosis?
The diagnosis is nonfatal strangulation from “the choking game.” The image depicts a ligature mark on his neck.
The choking game, or self-asphyxial risk-taking behavior (SAB), is defined as “self-strangulation or strangulation by another person with the hands or a noose/ligature to achieve a brief euphoric state caused by cerebral hypoxia.”1,2 The SAB activity causes obstruction of the cerebral venous and arterial blood flow, along with an increase in carbon dioxide, leading to a dizzy sensation. This brief euphoric or “high” feeling just before unconsciousness is then followed by a “rush” from the surge of blood flow when the constriction is removed.2–6 Unfortunately, serious injuries, long-term complications, and even death can occur as a result of this behavior.
“The choking game” is actually a misnomer. The pressure applied to the neck is actually strangulation, while choking refers to asphyxia due to internal airway obstruction. There are several other names for this form of SAB, including gasp, space monkey, suffocation roulette, funky chicken, sleeper hold, pass out, snuff, choke out, space cowboy, cloud nine, flatliner, dream game, knockout, breath play, rush, and the French term jeu du foulard.2,7
Signs and symptoms of the choking game are related to strangulation and cerebral hypoxia. Common manifestations include headache, loss of consciousness, unexpected neck bruising, seizures, bloodshot eyes, subconjunctival hemorrhages, facial/neck petechiae, disorientation after being alone, sudden visual loss, behavioral changes, head or musculoskeletal trauma due to falls, and ropes, belts, and scarves tied to bedroom furniture/doorknobs or found knotted on the floor. A thorough history and physical examination should be performed on patients ages 9 to 21 who present with any of these complaints. Direct questioning of the patient (without parents) may be needed. Treatment is based on identifying underlying injuries such as airway trauma, stroke, or possible carotid dissection. In cases of death, ED personnel should handle the case as possible suicide. Law enforcement and the medical examiner/coroner should be contacted to conduct a thorough investigation.
The choking game is most commonly performed by those ages 9 to 19 years (it peaks at 13 years of age), with a male-to-female ratio of 2-to-1.1,8,9 A review of choking game deaths by the Centers for Disease Control and Prevention (CDC) found 86.6 percent were males, with 13.3 years as the mean age. In the majority of deaths, the children died alone.7 Studies have shown that 6.6 percent to 17 percent of children/adolescents have performed the activity, and the vast majority of them have heard of the activity.2,5,8–11. Rural youth performed it more often than urban youth. Death rates are difficult to obtain because many cases may be misclassified as suicide. The CDC reported 82 deaths from the choking game from 1995 to 2007.7 The website GASP (Games Adolescents Shouldn’t Play) tracks choking game deaths from all over the world and has recorded more than 1,000 deaths.12
Despite children/adolescents’ knowledge of the activity, awareness among parents and physicians is much more variable.1,13,14 Studies have found that 40 percent to 50 percent of young people perceived no risk from SAB, making prevention and educational programs important. It is key not to sensationalize the behavior.2,15 A study showed that the popularity of SAB has been fueled by the Internet.8 The researchers found 419 YouTube videos of the choking game were viewed 22 million times. They postulated that the Internet has normalized the activity.
The choking game is a common yet potentially harmful activity that affects older children and adolescents. Physicians need to be educated about the activity, including the regional terms used to describe it as well as the common signs and symptoms participants may exhibit.
- The choking game, or self-asphyxial risk-taking behavior, can occur in older children, adolescents, and young adults.
- The behavior is perceived as a safer, harmless way to get “high,” although there may be serious injury and death.
- There may be regional variations in the terms used to described the activity.
- The actual mechanism is asphyxia leading to cerebral hypoxia due to alterations in cerebral blood flow.
- Parents and physicians need to be aware of the activity and have a high index of suspicion in appropriate patients.
Dr. Riviello isprofessor of emergency medicine at Drexel Emergency Medicine in Philadelphia.
Dr. Rozzi is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.
- Andrew TA, Macnab A, Russel P. Update on “the choking game”. J Pediatr. 2009;156(6):777-780.
- Re L, Birkhoff JM, Sozzi M, et al. The choking game: a deadly game. Analysis of two cases of “self-strangulation” in young boys and review of the literature. J Forensic Leg Med. 2015;30:29-33.
- Chow KM. Deadly game among children and adolescents. Ann Emerg Med. 2003;42(2):310.
- Howard P, Leathart GI, Dornhorst AC, et al. The mess trick and the fainting lark. Br Med J. 1951;2(4728):382-384.
- Macnab AJ, Deevska M, Gagnon F, et al. Asphyxial games or “the choking game”: a potential fatal risk behavior. Inj Prev. 2009;15(1):45-49.
- Ullrich NJ, Bergin AM, Goodkin HP. “The choking game”: self-induced hypoxia presenting as recurrent seizurelike events. Epilepsy Behav. 2008;12(3):486-488.
- Russell P, Paulozzi L, Gilchrist J, et al. Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years—United States, 1995-2007. MMWR Morb Mortal Wkly Rep. 2008;57(6):141-144.
- Defenderfer EK, Austin JE, Davies WH. The choking game on YouTube: an update. Glob Pediatr Health. 2016;3:2333794X15622333.
- Egge MK, Berkowitz CD, Toms C, et al. The choking game: a case of unintentional strangulation. Pediatr Emerg Care. 2010;26(3):206-208.
- Ramowski SK, Nystrom RJ, Rosenberg KD, et al. Health risks of Oregon eighth-grade participants in the “choking game”: results from a population-based survey. Pediatrics. 2012;129(5):846-851.
- Brausch AM, Decker KM, Hadley AG. Risk of suicidal ideation in adolescents with both self-asphyxial risk-taking behavior and non-suicidal self-injury. Suicide Life Threat Behav. 2011;41(4):424-434.
- Statistics. Games Adolescent Shouldn’t Play (GASP) website. Accessed Nov. 17, 2017.
- McClave JL, Russel PJ, Lyren A, et al. The choking game: physician perspectives. Pediatrics. 2010;125(1):82-87.
- Bernacki JM, Davies WH. Prevention of the choking game: parent perspectives. J Inj Violence Res. 2012;4(2):73-78.
- Deevska M, Gagnon F, Cannon WG, et al. An adolescent risk-taking behavior: “the choking game”. Pediatr Child Health. 2008;13(Suppl A):52.