The Choking Game All players lose.

(1)

The Choking Game

All players lose.

Carlos Flores, RN, MICN, Trauma Coordinator Carlos Flores, RN, MICN,

Trauma Coordinator

ABC 30 Action News

Story on the Choking Game

July 2007

ABC 30 Action News

Story on the Choking Game

July 2007

High risk activity in which single, pairs, or groups of youth induce an altered level of consciousness by restriction of the supply of

oxygen to the brain.

High risk activity in which single, pairs, or groups of youth induce an altered level of consciousness by restriction of the supply of

oxygen to the brain.

Hyperventilation Followed by: Valsalva Chest Pressure Carotid Occlusion Hyperventilation Followed by: Valsalva Chest Pressure Carotid Occlusion

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The “game” that’s not

The

The “

“game

game”

”

that’

that

’s not

s not

¾ Pass out

¾ The Scarf game ¾ The fainting game ¾ Knock out ¾ Black out game ¾ Flatline ¾ Choke out ¾ Airplaning

¾ America dream game ¾ Breath play ¾ Bum rushing ¾ Dream game ¾ Space monkey

¾ ¾ Pass outPass out ¾

¾ The Scarf gameThe Scarf game ¾

¾ The fainting gameThe fainting game ¾

¾ Knock out Knock out ¾

¾ Black out gameBlack out game ¾

¾ FlatlineFlatline ¾

¾ Choke outChoke out ¾

¾ AirplaningAirplaning ¾

¾ America dream gameAmerica dream game ¾

¾ Breath playBreath play ¾

¾ Bum rushingBum rushing ¾

¾ Dream gameDream game ¾

¾ Space monkeySpace monkey

¾Dying game ¾Dreaming game ¾Elevator ¾Flat Liner ¾Funky Chicken ¾Harvey Wallbanger ¾Space Cowboy ¾Trip to Heaven ¾California … ¾High ¾Headrush ¾Knockout ¾Choke ¾Dreaming ¾

¾Dying gameDying game ¾

¾Dreaming gameDreaming game ¾

¾ElevatorElevator ¾ ¾Flat LinerFlat Liner ¾

¾Funky ChickenFunky Chicken ¾

¾Harvey WallbangerHarvey Wallbanger ¾

¾Space CowboySpace Cowboy ¾

¾Trip to Heaven Trip to Heaven ¾ ¾California California …… ¾ ¾HighHigh ¾ ¾HeadrushHeadrush ¾ ¾KnockoutKnockout ¾ ¾ChokeChoke ¾ ¾DreamingDreaming

A picture is worth a

thousand words.

A picture is worth a

thousand words.

What it is not

AEA – Auto Erotic Asphyxiation

Choking game has no sexual

component.

Primarily Pre-adolescent and

adolescent age groups

AEA

–

Auto Erotic Asphyxiation

Choking game has no sexual

component.

Primarily Pre

-

adolescent and

adolescent age groups

(3)

Hyperventilation – “excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood.” Strangulation – “excessive or pathological constriction or compression of a bodily tube.”

Syncope – “loss of consciousness resulting from insufficient blood flow to the brain.”

Choking – “to keep from breathing in a normal way by compressing or obstructing the trachea or by poisoning or adulterating available air.”

Asphyxiation – “to kill or make unconscious through inadequate oxygen, presence of noxious agents, or other obstruction to normal breathing.”

Hyperventilation– “excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood.” Strangulation– “excessive or pathological constriction or compression of a bodily tube.”

Syncope– “loss of consciousness resulting from insufficient blood flow to the brain.”

Choking – “to keep from breathing in a normal way by compressing or obstructing the trachea or by poisoning or adulterating available air.”

Asphyxiation– “to kill or make unconscious through inadequate oxygen, presence of noxious agents, or other obstruction to normal breathing.”

Activity is played in

schoolyards, summer camps,

neighborhoods, homes.

Activity is played in

schoolyards, summer camps,

neighborhoods, homes.

Death from the choking game is estimated between 250 to 1000 in U.S.

Hard data is not available.

CA, TX, PA, OH, FL top 5 incident states.

Victims are mostly juvenile males but there are also female and adult victims of both genders.

Often, Medical Examiners indicate the manner of death as suicide.

Death from the choking game is estimated between 250 to 1000 in U.S.

Hard data is not available.

CA, TX, PA, OH, FL top 5 incident states. Victims are mostly juvenile males but there are also female and adult victims of both genders. Often, Medical Examiners indicate the manner of death as suicide. Jesse 12 yr Braden 12 yr Kyle 13 yr Stephan 16 yr Shawntae 14 yr Dylan 11 yr

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CDC Report Shows Largest One-Year Increase in Youth Suicide

Rate in 15 Years (2004)

Suicide rates for 10-19 year-old females and 15-19 year-old males increased significantly in 2004

Significant increase in suicide by hanging/suffocation.

Hanging was most common method among females. 71.4% in 10-14 age group. (2004)

Unintentional asphyxia is sometimes misclassified as suicide, however, these deaths are unlikely to account for the substantial increase.

(Pharmalive.com news archive) CDC Report Shows Largest

One-Year Increase in Youth Suicide Rate in 15 Years (2004) Suicide rates for 10-19 year-old females and 15-19 year-old males increased significantly in 2004 Significant increase in suicide by hanging/suffocation.

Hanging was most common method among females. 71.4% in 10-14 age group. (2004) Unintentional asphyxia is sometimes misclassified as suicide, however, these deaths are unlikely to account for the substantial increase.

(Pharmalive.com news archive)

2003 CDC 10 Leading Causes of Death Suicide is the 3rd_leading

cause of death in the 10-24 year age groups.

2003 CDC 10 Leading Causes of Death

Suicide is the 3rd_leading

cause of death in the 10-24 year age groups.

Multi-generational & World-wide - some accounts as early as the 1930’s with multiple countries reporting cases (France, Canada, Israel, England, Australia, Ireland).

No research data on it’s prevalence. Kids know about these games while their parents do not. Multi-generational & World-wide - some accounts as early

as the 1930’s with multiple countries reporting cases (France, Canada, Israel, England, Australia, Ireland).

No research data on it’s prevalence.

Kids know about these games while their parents do not.

Methods vary – hyperventilation, compression of chest and/or carotid arteries. Compression accomplished with arms, hands, or ligatures. Methods vary – hyperventilation, compression of

chest and/or carotid arteries. Compression accomplished with arms, hands, or ligatures.

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Ligatures are used in it’s most extreme form. Ligatures are used in it’s most extreme form.

¾Often played as a dare.

¾Induces brief sense of euphoria.

¾Euphoric effect may lead to addiction or obsessive behavior.

¾“It’s a drug in itself”

¾Amusing for some to watch others lose consciousness.

¾It’s free & legal. appears innocuous to those who don’t understand the mechanisms involved.

¾Stress relief?

¾Often played as a dare.

¾Induces brief sense of euphoria.

¾Euphoric effect may lead to addiction or obsessive behavior.

¾“It’s a drug in itself”

¾Amusing for some to watch others lose consciousness.

¾It’s free & legal. appears innocuous to those who don’t understand the mechanisms involved. ¾Stress relief?

Pathophysiology

¾

Hyperventilation

¾

Hypocapnea & Alkalosis

¾

Hemodynamic Depression

¾

Carotid Occlusion

¾

Accidental Asphyxia

¾ ¾

Hyperventilation

¾

Hypocapnea

& Alkalosis

¾

Hemodynamic

Depression

¾

Carotid Occlusion

¾

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Mechanism

¾Hyperventilation x 1 minute or longer ¾“hard” breath holding w/ forced

exhalation and no air escape

¾Valsalva maneuver

¾Self induced increase in lung air pressure ¾Bear hug, pressure added to the chest. ¾Occlusion of the carotid arteries by hands,

arms, or ligatures.

¾

¾ Hyperventilation x 1 minute or longer Hyperventilation x 1 minute or longer

¾

¾ ““hardhard””breath holding w/ forced breath holding w/ forced exhalation and no air escape

exhalation and no air escape

¾

¾ ValsalvaValsalvamaneuvermaneuver

¾

¾ Self induced increase in lung air pressureSelf induced increase in lung air pressure

¾

¾ Bear hug, pressure added to the chest.Bear hug, pressure added to the chest.

¾

¾ Occlusion of the carotid arteries by hands, Occlusion of the carotid arteries by hands, arms, or ligatures.

arms, or ligatures.

Hyperventilation, Hypocapnea,

& Alkalosis

Hyperventilation,

Hypocapnea

,

& Alkalosis

¾ Generally timed for over 1 minute ¾ Decrease in partial pressure of alveolar &

arterial CO2

¾ Increase in blood pH (Respiratory alkalosis) ¾ Vasoconstriction of blood vessels supplying the

brain.

¾ Pooling of the blood present in the brain. ¾ Brain rapidly uses up O2 available in pooled

blood.

¾ O2 concentration in the brain drops. ¾ Unconsciousness from hypoxia of cerebral

tissue.

¾

¾ Generally timed for over 1 minuteGenerally timed for over 1 minute ¾

¾ Decrease in partial pressure of alveolar & Decrease in partial pressure of alveolar &

arterial CO2

¾

¾ Increase in blood pH (Respiratory alkalosis)Increase in blood pH (Respiratory alkalosis) ¾

¾ Vasoconstriction of blood vessels supplying the Vasoconstriction of blood vessels supplying the

brain.

¾

¾ Pooling of the blood present in the brain.Pooling of the blood present in the brain. ¾

¾ Brain rapidly uses up O2 available in pooled Brain rapidly uses up O2 available in pooled

blood.

¾

¾ O2 concentration in the brain drops.O2 concentration in the brain drops. ¾

¾ Unconsciousness from hypoxia of cerebral Unconsciousness from hypoxia of cerebral

tissue.

Hemodynamic depression &

Carotid Artery Occlusion

Hemodynamic

depression &

Carotid Artery Occlusion

¾

Vagal Nerve Stimulus =

¾Decreased blood pressure ¾Decreased preload ¾Decreased cardiac output

¾

Baroreceptor / Carotid Sinus bodies

stimulus =

¾Decreased heart rate

¾

Vagal

Nerve Stimulus =

¾

¾Decreased blood pressureDecreased blood pressure

¾

¾Decreased preloadDecreased preload

¾

¾Decreased cardiac outputDecreased cardiac output

¾

Baroreceptor

/ Carotid Sinus bodies

stimulus =

¾

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Effects

¾ Numbness ¾ Tingling

¾ Light headedness & dizziness ¾ “see colored lights and stars” ¾ Giddiness

¾ Euphoria

¾ Neuromuscular irritability ¾ Muscular spasm

¾ Global brain hypoxia

¾

¾ Numbness Numbness

¾

¾ TinglingTingling

¾

¾ Light headedness & dizzinessLight headedness & dizziness

¾

¾ ““see colored lights and starssee colored lights and stars””

¾

¾ GiddinessGiddiness

¾

¾ EuphoriaEuphoria

¾

¾ Neuromuscular irritabilityNeuromuscular irritability

¾

¾ Muscular spasmMuscular spasm

¾

¾ Global brain hypoxia Global brain hypoxia

Ligatures

¾ Most extreme version ¾ Most lethal

¾ May be played alone

¾ Suicide by hanging vs accidental axphyxia by

hanging

¾ Rope, scarf, belt, necktie, plastic coated bike

chain, cloth towel dispenser, bed sheets, t-shirts, shoe laces, plastic bags, leashes, bungee cords,

¾ Bunk beds, closet door, swing set, closet rods,

basement pipe

¾

¾ Most Most extremeextremeversionversion

¾

¾ Most lethalMost lethal

¾

¾ May be played aloneMay be played alone

¾

¾ Suicide by hanging Suicide by hanging vsvsaccidental accidental axphyxiaaxphyxiaby by

hanging

¾

¾ Rope, scarf, belt, necktie, plastic coated bike Rope, scarf, belt, necktie, plastic coated bike

chain, cloth towel dispenser, bed sheets, t

chain, cloth towel dispenser, bed sheets, t--shirts, shirts,

shoe laces, plastic bags, leashes, bungee cords,

¾

¾ Bunk beds, closet door, swing set, closet rods, Bunk beds, closet door, swing set, closet rods,

basement pipe

Addictive Behavior is a possible result due to euphoria.

Repeated asphyxial events cumulative neurological damage

Addictive Behavior is a possible result due to euphoria.

Repeated asphyxial events cumulative neurological damage

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Opthalmological

¾ France

¾ 12 yr boy decreased visual acuity right eye

¾ Dense preretinal hemorrhage in the right eye

¾ After rule out of other factors, detailed history revealed boy played “scarf game” some hours prior to loss of vision

¾ 2 months post injury, full recovery of vision.

¾ ¾ FranceFrance ¾

¾ 12 yr boy decreased visual 12 yr boy decreased visual acuity right eye

acuity right eye

¾

¾ Dense Dense preretinalpreretinal hemorrhage in the right

hemorrhage in the right

eye

¾

¾ After rule out of other After rule out of other factors, detailed history

factors, detailed history

revealed boy played

revealed boy played ““scarf scarf

game

game””some hours prior to some hours prior to

loss of vision

¾

¾ 2 months post injury, full 2 months post injury, full recovery of vision.

recovery of vision.

Signs & Symptoms

physical findings

Signs & Symptoms

physical findings

¾ Syncopal events ¾ Headaches ¾ Bloodshot eyes ¾ Markings on neck – linear abrasions ¾ Hoarseness ¾ Petechia ¾ Facial flushing ¾ Disorientation ¾ Grogginess ¾

¾ SyncopalSyncopaleventsevents

¾

¾ HeadachesHeadaches

¾

¾ Bloodshot eyesBloodshot eyes

¾

¾ Markings on neckMarkings on neck––

linear abrasions linear abrasions ¾ ¾ HoarsenessHoarseness ¾ ¾ PetechiaPetechia ¾

¾ Facial flushingFacial flushing

¾ ¾ DisorientationDisorientation ¾ ¾ Grogginess Grogginess ¾ Scleral hemorrhage ¾ Conjunctival redness ¾ Short term memory

loss ¾ Seizures ¾ Retinal hemorrhage ¾ Stroke ¾ Unexplained bruises or lacerations to head

¾ Hypoxic brain injury,

brain death

¾

¾ ScleralScleralhemorrhagehemorrhage

¾

¾ ConjunctivalConjunctivalrednessredness

¾

¾ Short term memory Short term memory

loss loss

¾

¾ SeizuresSeizures

¾

¾ Retinal hemorrhageRetinal hemorrhage

¾

¾ StrokeStroke

¾

¾ Unexplained bruises Unexplained bruises

or lacerations to head or lacerations to head

¾

¾ Hypoxic brain injury, Hypoxic brain injury,

brain death brain death

Markings on neck / linear abrasions ligature marks

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Blood Shot Eyes Scleral

or conjunctival hemorrhage Blood Shot Eyes

Scleral or conjunctival hemorrhage Petichiae To face or neck Petichiae To face or neck

Signs & Symptoms

psychosocial

Signs & Symptoms

psychosocial

¾

Change in personality or behavior.

¾

Aggressiveness and agitation

¾

Questions about effects, sensations,

or dangers of strangulation

¾

Unusual need for privacy

¾

Change in personality or behavior.

¾

Aggressiveness and agitation

¾

Questions about effects, sensations,

or dangers of strangulation

¾

Unusual need for privacy

Signs & Symptoms

Environment

Signs & Symptoms

Environment

¾ Ligatures, ropes, belts lying about or found with

knots in unusual fashion

¾ Elusive reponse to questions about behavior or

findings

¾ “thud” heard in the bedroom, against a wall, or

behind closed doors

¾ Clothes covering neck abrasions ¾ Locked bedroom doors

¾ Wear marks on bunk beds, closet rods or dowels ¾ Visiting blogs, chat rooms, or websites, internet

use

¾ Increased alone time in room

¾

¾ Ligatures, ropes, belts lying about or found with Ligatures, ropes, belts lying about or found with

knots in unusual fashion

¾

¾ Elusive Elusive reponsereponseto questions about behavior or to questions about behavior or

findings

¾

¾ ““thudthud””heard in the bedroom, against a wall, or heard in the bedroom, against a wall, or

behind closed doors

¾

¾ Clothes covering neck abrasions Clothes covering neck abrasions

¾

¾ Locked bedroom doorsLocked bedroom doors

¾

¾ Wear marks on bunk beds, closet rods or dowelsWear marks on bunk beds, closet rods or dowels

¾

¾ Visiting Visiting blogsblogs, chat rooms, or websites, internet , chat rooms, or websites, internet

use

¾

(10)

Prevention

¾Let’s talk about it – awareness, education ¾Question the child if S&S are recognized ¾Let your child educate you

¾Discuss concerns being open and honest ¾Warn the child about the dangers of

accidental death or permanent disability

¾Advocate for education and other efforts

to add in safety curricula, such as D.A.R.E. programs

¾Supervision – cell phone, internet use,

alone time, school and social gatherings

¾

¾ LetLet’’s talk about it s talk about it ––awareness, educationawareness, education ¾

¾ Question the child if S&S are recognized Question the child if S&S are recognized ¾

¾ Let your child educate youLet your child educate you ¾

¾ Discuss concerns being open and honest Discuss concerns being open and honest ¾

¾ Warn the child about the dangers of Warn the child about the dangers of

accidental death or permanent disability

¾

¾ Advocate for education and other efforts Advocate for education and other efforts

to add in safety curricula, such as D.A.R.E.

programs

¾

¾ SupervisionSupervision––cell phone, internet use, cell phone, internet use,

alone time, school and social gatherings

If discovered or suspected

¾

Discuss with health care provider

¾

Professional counseling

¾

Verify siblings are not involved

¾

Alert school officials

¾

Alert parents of friends

¾

Discuss with health care provider

¾

Professional counseling

¾

Verify siblings are not involved

¾

Alert school officials

¾

Alert parents of friends

Gabriel, Samuel, and Sarah

May 2005

(11)

Websites

www.thedbfoundation.com

www.playinc.info

www.stop

-

the

-

choking

-

game.com

www.stilllovingmygabriel.com

VIDEO

bibliography

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SelfSelf--strangulation by hanging from cloth towel dispensers in Canadianstrangulation by hanging from cloth towel dispensers in Canadianschools. Le, D. Injury schools. Le, D. Injury Prevention, Sep 2001.

Prevention, Sep 2001.

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WikipediaWikipedia

Ophthalmological complications of the asphyxiophilic Ophthalmological complications of the asphyxiophilic ““scarf gamescarf game””in a 12 year old child. Gicquel, in a 12 year old child. Gicquel, JJ. Journal French Ophthalmology, Dec 2004.

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G.A.S.P. website G.A.S.P. website ––www.deadlygameschildrenplay.comwww.deadlygameschildrenplay.com