The risk of accidental childhood asphyxia in various recreational and
domestic settings has been repeatedly stressed, and represents an important
target for preventive action. In infants, most unintentional deaths associated
with asphyxia are sleep related—eg, suffocation by an overlying adult, smothering
by bedding or a pillow, or wedging between a mattress and bed frame(1).

Strangulation is less common in infants than in toddlers, and is very seldom
reported in the hospital setting. In 2004we investigated a fatal strangulation
by intravenous (iv) tubing during hospital treatment. A 10-month-old girl with a
history of acute lymphoblastic leukaemia was admitted to a local hospital for cytostatic
therapy and received iv antibiotics and liquids via a central venous catheter
for treatment of suspected sepsis. The patient’s temperature decreased over
the next few days to about 36ºC. 3 days after admission, the girl was restless in
the evening but eventually fell asleep after being given an analgesic. The
nurse on duty checked the infant early the next morning, at which time she
was sleeping; an hour later, the nursing staff found her lying prone in her crib.
She had no pulse, and was cyanotic and apnoeic. The iv tubing inserted into her
right clavicular vein was tightly wrapped twice around her neck. The
tubing was cut immediately, but despite prompt efforts at resuscitation
the girl was declared dead shortly after.

The case was referred to the Department of Forensic Medicine,
University of Helsinki, where an autopsy confirmed the cause of death as
asphyxia by strangulation. The National Authority for Medicolegal Affairs
investigated and concluded that there was no negligence by staff. All relevant
authorities were, however, informed as to the risks of strangulation associated
with iv tubing.

Unintentional strangulation by iv tubing and lines in hospital is rarely
reported. In addition to this case, only one other fatal has been described, in
Canada in 2002.(2) Two deaths were reported in the 1980s in the USA, but
details about the patients’ ages and circumstances surrounding the incidents
are unavailable.(2) Two non-fatal cases of strangulation, one by iv tubing and one
by the wires of a monitor, have also been described.(2,3) However, we believe
that fatal and non-fatal cases of strangulation might be more common than
a search of the published work implies; eventually, wider disclosure of such incidents
might lead to more effective prevention.

After the 2002 death, Health Canada(4) issued an official notice to all Canadian
hospitals, aiming to warn staff, parents, and care-givers about the risk of strangulation
posed by iv devices and monitor leads, and recommending
preventive measures—eg, individual risk assessment, an appropriate degree
of supervision, and use of accessories to stabilise flexible lines.
In addition to use of a rigid tube through which the iv line is run, Finnish
authorities also recommend a video surveillance system.

We declare that we have no conflict of interest.

*Philippe Lunetta, Maria Laari

philippe.lunetta@helsinki.fi
Department of Forensic Medicine, PL 40 (Kytösuontie
11), University of Helsinki, 00300 Helsinki, Finland
1 Drago DA, Dannenberg AL. Infant mechanical
suffocation deaths in the United States,
1980–1997. Pediatrics 1999; 103: e59.
2 Garros D, King WJ, Brady-Fryer B, Klassen TP.
Strangulation with intravenous tubing: a
previously undescribed adverse advent in
children. Pediatrics 2003; 111: e732–34.
3 Emery JL, Taylor EM, Carpenter RG, Waite AJ.
Apnea monitors and accidental strangulation.
BMJ 1992; 304: 117.
4Health Canada. Notice to hospitals: risk of
strangulation of infants by IV tubing and
monitor lead. Ottawa: Health Canada, Dec 29,
2003.
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