Accidental self-strangulation in a child.

Dear Sir,

Strangulation is an important cause of homicidal and suicidal injury in adults but in children it is usually accidental leading to death due to asphyxia as a result of partial hanging.[1] However in India strangulation injury is under reported.[2] Majority of pediatric and adolescent strangulation deaths are homicidal and only 7% are accidental.[3] Here we report a case of a 10-year-old female with accidental strangulation following suspension from an homemade hammock. The unique mode of injury has prompted us to report this case.

A 10-year-old girl was playing in a hammock made by slinging a sari from a rafter. The sari twisted and her neck was entangled in the twisted sari. She was discovered by her grandmother after an unknown period of time after the event. At this time she was suspended by the neck from the twisted sari and her feet almost touching the floor.

The girl was immediately removed from the sari sling and brought to the hospital by 2 hours. The child became unconscious and had one episode of generalized tonic clonic convulsions on the way to hospital. On arrival to the hospital she was unconscious (Glasgow coma scale of 8/15), decerebrating, opisthotonos posture with difficulty in breathing (RR 44/min). Her oxygen saturation 47% in room air, BP 100/58 mm of Hg, CFT <3 seconds, pupils dilated, and nonreactive. There was a ligature mark over the left neck [Figure 1]. There was no evidence of sexual abuse or other injury. Muscle tone was increased and deep tendon reflexes were brisk with bilateral extensor plantar response. Rest of the systemic examination was normal. She was intubated and started on inj. phenytoin and shifted to PICU for mechanical ventilation. Her investigations were as follows: Hemoglobin 14.2 g/dl, total leukocyte count 14,800/mm3, platelets 4.5 lakhs/mm3, sodium 139 mEq/l, potassium 5.5 mEq/l, urea 40 mg/dl, creatinine 1 mg/dl, and blood glucose 200 mg/dl. Arterial blood gases were normal. Neck X-ray did not reveal any hyoid or cervical vertebral fracture and computerized tomography (CT) scan of cranium and neck was normal. A medico-legal case was registered and the police investigated the case and ruled out any foul play. The child was managed with i.v. methyl prednisolone 30 mg/kg start, 5.9 mg/kg/h for next 24 hours, inj. mannitol, inj. ceftriaxone, inj. ranitidine along with mechanical ventilation. She had two episodes of convulsions during first 24 hours of admission. Her CT head after 2 days was again normal. She developed fever on the 3rd day and chest X-ray showed pneumonia. Endotracheal tube was sent for culture and started on inj. lenezolid and inj. amikacin. Gradually she was weaned off from the ventilator by 5 days. Her endotracheal tube culture grew staph aureus and klebsiella and were sensitive to amikacin and lenezolid. Throughout the PICU stay her kidney functions, blood glucose were normal. Her EEG showed abnormal spikes. She had increased tone of the limbs and brisk reflex for first 10 days and physiotherapy was given. She was started on syrup phenytoin, oral feeds by the 10th day and disharged after 21 days. At the time of discharge there was no speech, recognition of mother was present, could walk with support. By 6 weeks after discharge she started speaking and tiptoe walking.

Figure 1

Child on ventilator with ligature mark on the left side of the neck

The incidences of pediatric and adolescent deaths due to unnatural means are increasing.[3] Strangulation is a common method of homicide, but accidental ones like our case are rare. Accidental strangulation is a potentially fatal injury and various cases have been reported in children.[145] In a study of 28 cases of pediatric and adolescent strangulation from India, 7% of the cases were accidental and 93% homicidal.[3] However out of 30 cases of childhood strangulation, 23% cases were accidental in a study by Lockermann et al.[6] Clothing and personal belongings were found to be the most common ligature materials.[34] In our case also constriction of the neck by twisted sari acted as ligature and a mark was seen on the left side of the neck. Out of 28 strangulation cases 78.5% cases were due to ligature and clothing was the most common material used.[3] The prevalence of fracture of bone and cartilagenous structures was observed in 25% of cases.[3] In comparison to adults, children are at low risk of vertebral and laryngeal fractures, but are more susceptible to airway edema.[3] Our case did not had any fractures because fractures are common in adults due to ossification of these structures causing loosing elasticity and thereby fracture.[3] Spinal cord injury has rarely been documented in strangulation.[78] Methyl prednisolone was used in our case because of suspected cervical spinal cord injury (persistent opisthotonos position and hypertonia of all the limbs at admission). Nearly one-third of cases have seizures due to neurological damage as in our patient.[2] Neurological damage and death are caused by airway obstruction, and venous congestion leading to hypoxia, acidosis, brain congestion, and brain cell death.[1478] Pulmonary complications like aspiration pneumonia, bronchopneumonia, and adult respiratory distress syndrome are the major causes of mortality and morbidity.[89] Even our case also had ventilator-associated pneumonia and was treated with appropriate antibiotics. Management of these cases requires intensive monitoring and supportive care, maintenance of airway, circulation and management of seizures, and cerebral edema.[1] Prognosis depends on the duration of unconsciousness, the presence of seizures, diabetes insipidus, or hyperglycemia at admission.[9] The mortality rate in strangulation is high and full neurological recovery has never been reported for those who presented with cardiac arrest.[7] All resuscitative efforts should be undertaken in patients to establish cerebral blood flow, because intact neurological survival is possible even in deeply comatose patients.[7] A good response to initial resuscitation is an important prognostic factor for eventual recovery. Survivors may have cognitive disabilities later on due to hypoxic-ischemic injury to the hippocampus.[810] Out of 12 children who survived 10 were normal and 2 had neurological sequelae on follow-up and authors concluded that extent of the initial injury and effectiveness of resuscitation were the major determinants of outcome.[9] To conclude, strangulation injuries in children are not common but they could be potentially fatal because of its neurological and respiratory complications. Accidental strangulation of this variety is easily preventable if the children are not left unattended. Parental education is necessary to ensure child safety.