Strangulation, suffocation and asphyxial injury — formative SAQs

SAQ 1 (10 marks)

A four-month-old boy is brought to the emergency department cold, pale and apnoeic after being found face-down in the soft bedding of the parental bed, where he had been sleeping beside his mother after a feed. Resuscitation is in progress. There are faint petechiae on his face and conjunctivae. His mother is distressed and says she "only dozed off for a moment." [1] [8]

1. Give your immediate resuscitation and safeguarding actions, including how you would preserve the scene, and the further investigations you would arrange. (4) [1]
2. Explain why this infant is uniquely vulnerable to asphyxia, and what the petechial haemorrhages do and do not prove. (3) [6] [10]
3. Describe how you would reason about the question of accidental overlay versus inflicted suffocation, and what you would tell the family. (3) [7] [8]

Model answer — SAQ 1

(1) Resuscitation and safeguarding (4). Resuscitate the hypoxic brain: protect and open the airway, support breathing and circulation with bag-valve-mask ventilation escalating to intubation for apnoea, and begin cardiopulmonary resuscitation if there is no pulse; treat the reversible causes of secondary brain injury — hypoxia, hypotension, hypoglycaemia, fever and seizures — and involve paediatric intensive care early. Run safeguarding and scene preservation from minute zero: do not "tidy" the scene, note and photograph the position, the bedding and the objects before anything is moved, secure any product involved, inform the consultant and the child-protection team, and make the mandatory report required by your jurisdiction. Arrange a blood gas, lactate and glucose; an ECG to screen for a cardiac cause; sepsis, metabolic and toxicology screens; a CT head for any neurological sign; and, where the story is unclear, a full inflicted-injury workup with skeletal survey, dilated ophthalmology and a coagulation screen. Treat the family with respect and without accusation throughout. [1]

(2) Infant vulnerability and petechiae (3). The infant is uniquely vulnerable because of a disproportionately large heavy head on weak neck muscles, a small compliant airway that occludes against a soft surface, obligate nasal breathing in the first months of life, and a low functional reserve that turns a short apnoea into rapid, profound hypoxia — the Vennemann German SIDS study confirmed that prematurity, prone sleeping and hazardous sleep environments amplify one another in the most vulnerable infants. The facial and conjunctival petechiae support an asphyxial mechanism, but the Ely and Hirsch review is explicit: petechiae are absent in many genuine suffocations, occur in non-asphyxial deaths and after prolonged resuscitation, and never, on their own, prove suffocation or distinguish accidental from inflicted injury. [6] [10]

(3) Accidental overlay versus inflicted suffocation (3). The body alone often cannot separate the two, so the decision rests on the scene, the history, the findings and the social context weighed together by the multidisciplinary team. Ask whether the account is consistent, developmentally plausible and concordant with the scene — the position, the bedding, who else was present, any prior unexplained events and any previous sibling death. The Blair case-control study showed that the modifiable hazardous cosleeping factors — soft bedding, sofa-sharing, bed-sharing with an adult who had drunk alcohol or smoked, and prone positioning — cluster in the deaths and may point to a genuine accidental overlay in a known hazardous setting. Where the story shifts or is implausible, or there are recurrent unexplained events, induced or inflicted suffocation (the entity the Southall covert-video work documented) must be considered and child-protection involvement escalated. To the family I would be honest, calm and non-judgemental: explain that several possibilities exist, that a careful multi-agency assessment is needed, and that the team's duty is to keep the child safe while it completes — presenting a probability, not a verdict. [7] [8]

SAQ 2 (10 marks)

A three-year-old girl is found hanging by the neck from a looped window-blind cord in her bedroom. She is cut down by her father, who calls for help. On arrival in the emergency department she has a clear ligature groove on her neck, stridor, and a depressed conscious level. In parallel, the paediatric registrar is asked to counsel the parents of a new baby about safe sleep at the six-week check. [1] [7]

1. Outline the immediate management of the cord-strangulation child and the specific asphyxial signs you would document. (4) [1]
2. Give the safe-sleep and product-hazard prevention advice you would deliver at the six-week check, naming the evidence base. (3) [1] [8]
3. Explain how you would recognise and respond to suspected induced or inflicted suffocation in an infant. (3) [7]

Model answer — SAQ 2

(1) Cord-strangulation management and documentation (4). Resuscitate the hypoxic brain: secure the airway — be prepared for early intubation given the stridor and depressed conscious level, and for cervical injury and airway oedema — support breathing and circulation, begin CPR if there is no pulse, and treat seizures, hypoxia, hypotension and hypoglycaemia with neuroprotection and paediatric intensive-care input. Investigate with a blood gas, lactate and glucose; an ECG; a CT head for the altered responsiveness; and an inflicted-injury workup if the account is implausible. Document the specific asphyxial signs: the ligature groove on the neck, facial and conjunctival petechiae above the compression line, grip bruising or patterned abrasions, frothy pulmonary oedema, and the neurological state — all recorded contemporaneously, with photographs where the local protocol allows, before the scene is disturbed. Preserve the cord and inform the consultant and child-protection team from the first minute. [1]

(2) Safe-sleep and product-hazard prevention (3). The safe-sleep ABCs are the AAP 2022 recommendations and their evidence base: the baby sleeps Alone, on the Back, in a bare Crib — a firm flat surface with no soft bedding, pillows, bumpers or loose objects; room-sharing without bed-sharing; avoidance of smoke, alcohol and any impaired adult; and breastfeeding where possible. Extend the message to product hazards: fit cordless window blinds or tension devices, cut looped cords and keep cots and furniture away from windows; keep small objects, plastic bags and drawstrings out of reach; and check cots and bunk beds for gaps. The Blair case-control study showed the highest risk attaches to sofa-sharing and bed-sharing with an impaired or smoking adult — factors amenable to a targeted, non-judgemental message delivered in the family's own language. [1] [8]

(3) Induced or inflicted suffocation (3). The red flags are an infant with recurrent, witnessed or unexplained apnoea, a story that changes between tellings or is developmentally implausible, a previous sibling death, or a child whose life-threatening events resolve only when removed from a carer's care — the entity the Southall covert-video study documented. The response is a low threshold for child-protection involvement and covert investigation: treat every unexplained infant collapse as a safeguarding event from the first minute, reconstruct the scene, take a verbatim multi-source history, arrange a full inflicted-injury workup, screen siblings and household contacts for occult injury and unexplained events, and keep the child in a safe place while the multidisciplinary assessment and the statutory child-death process complete. The discriminating move is to present a probability grounded in the whole picture, because the mortality of missed inflicted suffocation is high. [7]