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We read with interest the emergency casebook featuring two cases of near asphyxiation.1 It is our practice to admit all cases of near strangulation who present early with signs or symptoms in keeping with the history for a period of observation. We adopt this policy on the basis that it is possible to miss occult, significant upper airway pathology in victims of near strangulation2 and airway obstruction can present as late as 36 hours after such an event.3 In addition it is possible to overlook visual impairment in such patients as subtle changes in visual acuity may not initially be apparent.4 Cases of near asphyxiation in children are not widely reported in the literature and therefore it is difficult to have an evidence based admission/discharge policy. Are we being over cautious?
Author's reply
We agree entirely, the experience with asphyxiation in children is limited and therefore there is no evidence base as to what is the most appropriate admission/discharge policy. At the Birmingham Children's Hospital we are fortunate in being able to observe less sick children in an accident and emergency based observation bay, in case they get delayed respiratory symptoms, and therefore do not need to admit many children to the paediatric wards.
We were interested to note the reference to subtle changes in visual acuity by Baldwin et al.1 This suggests it would be wise to consider visual acuity testing a few weeks after such an incident and we would certainly look towards arranging ophthalmological follow up with these patients in the future.