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.

Key Points

• 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.

Complete the CME activity.

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.

References

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