Case 164

Nina Mbadiwe


An 18-month-old boy is brought to the emergency room after his parents found him with a window cord wrapped around his neck. Currently, he is awake and alert with normal vital signs for age. His physical exam is unremarkable except for ligature marks on his neck.

What are the findings seen in strangulation and hangings? What is the most common cause of death in window cord strangulation injuries?



Strangulation in children is usually accidental but can also be a form of child abuse. Hanging, with strangulation and suspension of the neck, is classified as either complete with the entire body hanging off the ground or incomplete, with a portion of the body touching the ground and the weight not fully supported by the neck. Theories of the pathophysiology during strangulation and hanging include:

  • Venous obstruction leading to hypoxia and loss of consciousness
  • Arterial spasm caused by pressure on the carotid artery leading to decreased cerebral blood flow
  • Vagal collapse due to the pressure on the carotid sinuses and increased parasympathetic tone.

In all forms of strangulation, death is ultimately due to cerebral anoxia and ischemia with obstruction of cerebral venous return (vessel occlusion) rather than acute airway compromise.

Physical exam findings include abnormal vital signs, facial edema, petechiae, neck contusions and/or ligature marks around the neck, voice changes, difficulty swallowing, and respiratory symptoms.

Injury prevention is an important topic to address with parents and caregivers. Cribs, beds, furniture, and toys need to be placed away from windows. Window cords should be out of reach, either tying them up high or anchoring them to the wall. Cordless window coverings are the best option in children’s bedrooms and play areas.

Keywords: blunt trauma, neck injury, airway


Muthukrishnan L, Raman R, Nagaraju K. An unusual cause of accidental hanging in a toddler. Pediatr Emerg Care 2012;28(9):924–5.

Sabo RA, Hanigan, WC, Flessner K, Rose J, Aaland

M. Strangulation injuries in children. Part 1. Clinical analysis. J Trauma January 1996;40(1):68–72.

Tintinalli JE. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill Education, 2016.

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