Clinical Consequences of Self‐Induced Hypocapnia

Abstract

Adolescence is a vulnerable period for participation in a lot of risky behaviours, including the choking game, a dangerous practice whose consequences can be fatal. 1 We report a case of an 11-year-old boy referred for ataxia, disorientation and slurred speech. The boy had participated in a game based on bending over, hyperventilating and being hit in the chest. He suffered no loss of consciousness. He denied drug use. Neurological examination revealed incoherent speech, psychomotor agitation with alternating periods of lethargy and ataxia and an amnesia episode. The rest of the physical examination was normal (cranial nerves, pupillary response, strength and muscle tone). Blood count, biochemistry, toxic urine, brain scan, magnetic resonance imaging, and electroencephalogram were all normal. The child's neurological status improved rapidly, with full recovery of cognitive function after four hours of observation.The choking game is usually performed by teenagers and produces temporary interruption of cerebral perfusion. It can be achieved by different techniques such as bilateral neck compression, throttling themselves with ropes, or holding the breath and getting punched in the chest. The choking game seems to begin in groups. Individual practice is associated with increased risk of mortality. 2This patient was of particular interest because the mechanism used (holding the breath and getting punched in the chest) is not very common. Most cases reported in the literature describe bilateral neck compression as the principal mechanism to achieve self-induced hypocapnia.2 This entity can lead to cerebral vasoconstriction, increased cytokines 3 production and hypoxia. Syncope, seizures and cognitive deficits have been reported as immediate side effects. The differential diagnosis of these behaviours should include suicide and auto-erotic asphyxiation. 4 The suicide attempts often occur during late adolescence, while asphyxic games occur during early adolescence and often there is a history of previous attempts. The doctor should examine the patient looking for possible signs of self-injury such as marks on the neck or bloodshot eyes. These practices are becoming more common among adolescents. It is thought that many of the deaths result from engagement in this activity while alone. 2 The internet is a dangerous source of information about such games. Multidisciplinary work with psychologists and educators and participation in community prevention programs is required.