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Two cases of near asphyxiation in children, using non-releasing plastic garden ties
  1. N Makwana,
  2. H M Evans,
  3. D Moore,
  4. K Berry
  1. Accident and Emergency Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
  1. Correspondence to: Dr Makwana, Senior House Officer (niten{at}

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We present two cases of children recently seen in our accident and emergency (A&E) department with near asphyxiation attributable to non-releasing plastic garden ties around the neck.

Case 1

A 6 year old boy presented after his older brother had put a non-releasing garden tie around his neck during unsupervised play in the garden. He was unable to release the tie and in his attempt to do so, pulled it tighter. Fortunately, his grandmother was quick to respond and cut the tie off with kitchen scissors. On examination, he had petechiae over his face but neither neck swelling or apparent trauma to his larynx. He had a 1 cm × 1 cm, V shaped laceration to his neck where the tie had been cut off. He required no treatment other than a warning of the obvious dangers of his actions.

Case 2

A 10 year old boy arrived as a helicopter transfer to the Birmingham Children's Hospital Accident and Emergency Department after near asphyxiation secondary to a similar but larger non-releasing tie around the neck. This incident occurred on a golf course and his father's attempts to remove it only served to tighten it further. No one had a sharp implement to hand and the ligature was in place for 5–10 minutes before finally being removed. When the paramedic team arrived, the child was unresponsive but self ventilating. On assessment in the A&E department he had facial congestion with central cyanosis with extensive well demarcated petechial haemorrhages from the neck upward and bilateral conjunctival haemorrhages (fig 1). He was extremely agitated and confused, being totally uncooperative. He was stabalised, intubated and ventilated. Subsequently he underwent computed tomography, which showed mild cerebral oedema. He was transferred to the paediatric intensive care unit for monitoring and was extubated that evening with no apparent neurological deficit. He was observed for a further 48 hours and was fortunate to survive this episode without sustaining major neurological injury.

Figure 1

Case 2 showing the facial petechiae and subconjunctival haemorrhages, typical of ligature strangulation.


There are no similar reported cases of near asphyxiation of these widely available garden ties. Some reported cases of asphyxiation in children include accidental strangulation including drawstrings,1 car electric windows,2 and stroller prams.3 All these cases proved fatal.

Clinical features of ligature strangulation resemble those of non-judicial hanging as there is no significant drop involved and injury occurs secondary to compression of neck structures. The features include marks around the neck from the device used for hanging as well as skin and subconjunctival petechial haemorrhages because of increased venous pressure.4 These are not invariable but were found in both cases presented here.

The treatment of both our patients was principally supportive with endotracheal intubation as necessary. Cervical spine injury has not been reported and is unlikely in ligature strangulation victims. As in one of our cases severe neurological deficit may be reversed and despite initial findings victims should be aggressively resuscitated.5

Our cases illustrate the inherent dangers of the non-releasing plastic garden tie. Their design means that even small children are able to manipulate them but once tight find it impossible to effect release. These ties are widely available in do it yourself stores and garden centres and can also be used for tying electrical flexes. The products we examined did not display any warnings on the packaging. Easy release versions of this product exist and, for the majority of purposes, a non-releasing tie is perhaps not the most practical design and adjustable ones would be more suitable.

Except when non-release is essential for security reasons outside the domestic setting, for example, clinical waste, we would strongly advocate the use of the releasable versions and recommend that non-releasing ties display a clear warning on their packaging to keep them out of the reach of children.