Suffocation Injuries in the United States

Patient Characteristics and Factors Associated With Mortality

Roula Sasso, MD; Rana Bachir, MPH; Mazen El Sayed, MD, MPH


Western J Emerg Med. 2018;19(4):707-714. 

In This Article

Abstract and Introduction


Introduction: Asphyxiation or suffocation injuries can result in multi-organ damage and are a major cause of morbidity and mortality among different age groups. This study aims to describe characteristics of patients presenting with suffocation injuries to emergency departments (EDs) in the United States (U.S.) and to identify factors associated with mortality in this population.

Methods: We conducted a retrospective cross-sectional study using the 2013 U.S National Emergency Department Sample database. ED visits with primary diagnoses of intentional or accidental suffocation injury, and injury by inhalation and aspiration of foreign bodies or food (ICD-9-CM codes) were included. We performed descriptive statistics to describe the study population. This was followed by multivariate analyses to identify factors associated with mortality.

Results: We included a total of 27,381 ED visits for suffocation injuries. Most suffered from either inhalation and ingestion of food causing obstruction of respiratory tract or suffocation (51.6%), or suicide and self-inflicted injury by hanging, strangulation, and suffocation (39.4%). Overall mortality was 10.9%. Over half (54.7%) of the patients were between 19 and 65 years old. Males were more common than females (59.1% vs. 40.9%). Over half of the patients (54.9%) were treated and released from the ED. Factors associated with increased mortality included male gender, young age (4-18 years), diseases of the cardiac, respiratory, genitourinary and neurologic systems, intentional self-harm, and self-payer status.

Conclusion: Mortality from suffocation injuries remains high with significant burden on children and adolescents and on patients with intentional injuries. Tailored initiatives targeting identified modifiable factors through implementation of behavioral and environmental change can reduce the risk of suffocation injury and improve clinical outcomes of affected victims.


Asphyxiation or suffocation can be defined as the deprivation of oxygen supply to body tissues and can result from mechanical or non-mechanical constriction of the airway or from a decrease in breathable gas in the respired surrounding atmosphere.[1] Suffocation and asphyxiation can vary at the forensic pathology level;[1] however, both can be used interchangeably to report a decrease in oxygen delivery to the lungs resulting in deprivation of oxygen or hypoxia.[2,3]

Suffocation injuries and death can result from suicidal attempt, assault or accidental injury. In parts of Europe and Asia, intentional asphyxiation by hanging is the leading manner of suicide attempts.[4,5] In the United States (U.S.), the rate of suicide by intentional asphyxiation is second only to suicide by firearms.[6] Choking is a form of unintentional asphyxiation: choking was the third leading cause of unintentional deaths in the U.S. between 2000 and 2013 in adults aged 65 years or older[7] and a leading cause of morbidity and mortality among children aged less than 3 years.[8] In addition to death and multi-organ damage, complications of asphyxiation include cardiopulmonary injuries and neurological injuries, in addition to orthopedic injuries with hangings and strangulation.[9–11]

The current medical literature describing suffocation injuries and clinical outcomes is limited and is mostly focused on death from asphyxiation by hanging or strangulation injuries.[12–16] Available medical literature suggests that cardiopulmonary resuscitation at the scene of suffocation injury is associated with improved clinical outcomes while longer duration of hanging is associated with increased mortality in cases of hanging asphyxiation.[17] Low Glasgow Coma Scale on arrival to the emergency department (ED) has also been associated with poor clinical outcomes.[18] Understanding the epidemiology of suffocation injuries, characteristics of affected victims and factors associated with mortality is important for physicians and policymakers to tailor prevention initiatives and mitigation strategies.

Our goal was to describe the characteristics of patients presenting with suffocation injuries to EDs in the U.S and to identify factors associated with mortality in this population.