1. Games adolescents shouldn’t play Erin Reeve, RN, BSN, CEN, FCN

2. Objectives
You will be able to identify signs and symptoms in a child who is “playing the choking game.”
You will be able to describe the pathophysiology of brain cell death with the use of this practice.
You will understand how to teach youth how to respond to those encouraging this practice.
Understand current statistics on this practice and how deadly it has become in the teen population.

3. Choking game defined:
Known as “the choking game”, this practice occurs mainly in the young adolescent and teen ages, and has brought forth untimely death in too many children.
It refers to intentionally cutting off the oxygen supply to the brain with the goal of producing a temporary syncope and euphoria.

4. During school, to get out of class
Reasons Kids do this?
During school, to get out of class
Peer pressure; challenge of a dare; a rite of passage into a social group; amusement over erratic behavior.
Curiosity in an altered state of consciousness
A belief it induces euphoria
Intensifying an existing high while under the influence of ecstasy or LSD.
The prospect of intoxication, at NO COST.

5. Demographics:
The majority of participants are male (87% in 2008 data). Yes, girls die, too.
North Carolina had a rate of 25% female in 2008, higher than the average of 13%.
Age ranges from 6-19 years, with the most fatalities in the year range.
In 2008, 45 states had reported cases.
This has no geographic boundary; it happens in rural and metropolitan areas, alike.

6. Demographics:
In 2008, Texas and California had the highest number of cases.
96% of deaths occurred while the youth was ALONE.
93% of the parents had never heard of this practice until their child died from it.
The actual rates of death from this practice is probably much higher than is reported; many are deemed a suicide by hanging;

7. Demographics:
From , deaths attributed to the choking game numbered 82 (U.S.) in youth aged 6-19 years.
From , deaths due to choking game in USA=135.
The number of deaths attributed to suicide by hanging/suffocation in youth age 6-19 years numbered 5,101 from
Source: Choking game deaths, news media reports, suicide by hanging/suffocation, National Vital Statistics System.

8. Additional Age Info: 2011: 9,11,12, 13 & 17 year olds have died
2010: ranges from 8-21, with ages 12, 13, & 14 tied as largest group range
2009: ages 6-23; age 13 largest group
2008: ages 7-20, 22,28, 30, & 37. Age 12, again, had the highest number cases.
2007: ages 7-23, 25, 41, & 51. Age 12 had the largest group.

9. Countries Affected:
USA, Canada, India, France, Ireland, Korea, Malaysia, Peru, South Africa, Australia, Egypt, England, Germany, New Zealand, Jamaica, Russia, Scotland, Greece, Italy, and Mexico.

10. New Data: Known stats 2011: 8 deaths in USA and 1 recovery,
1 death in England,
2010: 42 cases worldwide, 25 were USA; 10 USA cases recovered.
2009: 75 cases worldwide, 47 were USA; 18 USA cases recovered.
2008: 126 cases worldwide: 84 were USA; only 5 of those recovered
2007: 147 worldwide cases. 77 were from USA; 12 recovered

11. 2 Mechanisms of Injury
A ligature around the neck or pressure on the internal carotid artery, known as STRANGULATION, causes two significant responses:
1. Pressure on the carotids also induces pressure on the baroreceptors, which cause vasodilation in the brain leading to insufficient brain perfusion, thus unconsciousness occurs.

12. 2 Mechanisms of Injury:
2. A message via the vagus nerve to the SA node decreases the rate and volume of cardiac output, typically by up to 1/3. This may escalate into asystole. With no heartbeat, no oxygen, death may result.

13. 2 Mechanisms of Injury: SELF-INDUCED HYPOCAPNIA
This requires hyperventilation until symptoms of hypocapnia occur, such as tingling, light-headedness dizziness. Then, holding the breath or having the chest compressed by an accomplice. These actions may augment the effects of hypoxia by causing more vagal stimulation.

14. 2 Mechanisms of Injury:
Hyperventilation leads to excessive elimination of CO2. No additional O2 is breathed in. The blood becomes abnormally alkaline. Alkalosis interferes with normal oxygen use by the brain. Symptoms include neuromuscular irritability, muscle spasms, numbness & tingling of the extremities and circumoral areas, dizziness, & giddiness, often interpreted as euphoria.

15. 2 Mechanisms of Injury:
Alkalosis generally induces vasodilation in the body, but in the brain, it causes vasoconstriction. This vasoconstriction is worsened by a sudden increase in blood pressure caused by holding the breath. The alkalosis-induced euphoria can lead rapidly to hypoxia-induced unconsciousness.
The brain has a very low tolerance for hypoxia if vasoconstriction is not reversed.

16. 2 Mechanisms of Injury:
Normally, if the brain is hypoxic, the ANS in the body diverts blood to the brain. Because the brain is vasoconstricted, this mechanism is not available. Vaso-
constriction is reversed when CO2 builds up in the blood. If this buildup does not happen quick enough, or vasodilation does not occur, irreversible brain damage or death is a reality.

17. Results of the Practice:
With strangulation and self-induced hypocapnia blackouts, the victim my experience dreaming, hallucinations, short-term memory loss, seizure-like activity. Full recovery usually occurs within seconds, but these activities may cause permanent brain injuries or death, particularly when “played” alone or with a ligature.

18. Common names in UK, USA, and Australia:
Fainting game, Riding a Rocket, Airplaning, America Dream Game, Black Out, Breath Play, Bum Rushing, California Choke, California Dreaming, California High, California Knockout, Choking out, Cloud Nine, Dying game, Dream game, Elevator, Flatline Game, Flatliner, Funky Chicken, Harvey Wallbanger, Hyperventilation Game, Indian Headrush, Knockout game, Pass-out game, natural high, sleeper hold, Space Cowboy, Space Monkey, Suffocation game, Suffocation Roulette, Teen choking game, Rising Sun, High Riser, Tingling Game, Trip to Heaven, Rocket Ride, Speed Dreaming, Wall-Hit, and Purple Dragon.

19. Other information:
Unlike autoerotic asphyxia, this practice is NOT COMMON IN ADULTS, but has been done by adults.
It can be ADDICTIVE.
Sources for information include:

20. Signs to look for:
Discussion of the game and it’s terms; bloodshot eyes; marks on the neck; severe headaches; disorientation after spending time alone; ropes, scarves, and belts tied to bedroom furniture or doorknobs, or found on floor; unexplained presence of items like dog leashes, choke collars, bungee cords, etc.

21. Bibliography Fainting Game. http://en.wikipedia.org/. 11/01/2010.
GASP: Choking Game Community Support. Accessed 11/01/2010, 4/8/2011..
Gardner, Amanda. ‘Choking Game’ Turned Deadly. 2/14/2008. The Washington Post.
Statistics. Accessed 10/2/2010 & 4/8/2011.