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Survival from accidental strangulation from a scarf
resulting in laryngeal rupture and carotid artery stenosis:
the “Isadora Duncan syndrome”. A case report and
review of literature
P A Gowens, R J Davenport, J Kerr, R J Sanderson, A K Marsden
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Emerg Med J 2003;20:391–393

In 1929 the dancer Isadora Duncan died from strangulation and carotid artery insult when her scarf caught in the
wheels of a motor vehicle in which she was travelling. As
part of the Edinburgh Festival scene, cycle propelled rickshaws are in popular use as short range taxis. The case is
presented of a student who sustained a laryngeal rupture
from strangulation with a scarf in the same way as Isadora.
Despite an out of hospital cardiorespiratory arrest, severe
laryngeal trauma, and carotid artery damage resulting in
hemiparesis, the patient was successfully resuscitated and
recovered with no neurological deficit. It is believed that
this is the first recorded survival from this condition.

I

n the early hours of a June morning in 2001, an ambulance
was dispatched to a suspected case of “choking” in a main
Edinburgh street. On arrival six minutes later a 21 year old
woman was found lying in the recovery position, apparently
strangled from her scarf, which had become caught in the
wheels of a cycle powered rickshaw. Bystanders had loosened
the ligature (scarf) with difficulty but no other first aid measures had been undertaken.
Initial assessment was extremely difficult. Assessment of
the airway was virtually impossible on account of gross
oedema of the neck and face and massive surgical emphysema. However, the patient was apnoeic and unresponsive to
painful stimuli. The neck oedema made it impossible to
palpate the carotid pulses but cardiac arrest was presumed
from the absence of the other major pulses. Airway control
was achieved by jaw thrust; chin lift with a bystander
maintaining c-spine support. The patient was ventilated by
bag-valve-mask with supplemental oxygen delivered through
a reservoir. Tracheal intubation was not possible, as, during
laryngoscopy, the normal laryngeal landmarks could not be
visualised.
Initial CPR was stopped after a few minutes because,
although the pulses remained impalpable, the patient made
occasional physical movement and some respiratory effort.
A collar was applied, intravenous access obtained, and the
patient was made ready for rapid transport to hospital.
Assisted ventilation was continued though there were some
irregular spontaneous respirations with marked laryngeal
noises heard.
En route to hospital the patient had a seizure followed by a
right sided facial weakness.
On arrival at hospital the vital signs were RR18 with stridor,
radial pulse rate 104, GCS – E1, M5, V1 and, despite the obvious partial airway obstruction, the initial SPO2 was recorded as
99%.
There was great difficulty in securing a definitive airway
because an attempt at conventional intubation by senior
accident and emergency staff and anaesthetic staff failed

Figure 1

Fractured hyoid bone in accidental stangulation.

because of the gross dissention of the normal laryngeal
architecture. These attempts had been supported by the
administration of short acting agents, propofol and halothane. Eventually, nearly two hours from onset, a definitive
“airway” was obtained by diathermic cricothyroidotomy carried out by a specialist ENT surgeon. The airway was secured
with a cuffed tracheostomy tube.
Radiology revealed a hyoid bone fracture consistent with a
strangulation injury (fig 1). The cervical spine appeared
intact.
With a clinical diagnosis of traumatic carotid artery stenosis, the patient was transferred to the regional neuroscience
unit for neurosurgical intensive care. Computed tomography
showed no intracranial abnormality. Neither vascular investigation nor therapeutic interventions were required with the
hemiparesis resolving spontaneously over the next 12 weeks.
The patient was able to be discharged after four months. A full
neurological recovery has taken place though the patient has
required further re-constructive laryngeal surgery.

LITERATURE REVIEW
The possibility of death from strangulation by a scarf caught in
the wheel spokes of a vehicle was brought to the public’s
attention when the world famous dancer Isadora Duncan died
on 14 September 1929. The long scarf, which she was wearing,
became caught in the wire wheels of her Buggati car, stopping
the vehicle. Isadora died at the scene and was later found to
have sustained a fractured larynx and carotid artery injury.1
Cycle powered rickshaws (fig 2) remain a common form of
transport in some parts of India. However, the unprotected
spokes of the cycle wheel can trap the long scarf (chunni)
worn by Indian women and a number of cases of accidental
strangulation have been described—with no recorded

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392

Gowens, Davenport, Kerr, et al

Figure 2 Cycle powered rickshaw.

survivors.2 3 Aggarwal from the Department of Forensic Medicine at Delhi has described a number of common features
including the persistence of unconsciousness from the outset
with death confirmed soon after arrival at hospital.
Closed injury to the larynx most frequently follows blunt
injury to the neck with some “classic” presentations including
the two wheeled motorist running into an ambush wire or the
unguarded tailgate of a lorry. The clinical features of
dysphagia, hoarsenss, and dyspnoea are related to the gross
oedema and/or the distortion of the laryngeal skeleton
including fracture of the hyoid and/or dislocation of the arytenoid cartilages.4 Carotid artery injury, also, usually follows
blunt trauma and has been described following karate blows
to the neck,5 6 diving,7 therapeutic manipulations,8 and
assaults. It occasionally requires endarterectomy with the use
of stents.
When the traumatic insult is severe such as in strangulation, which is described here, or in hanging, it is not uncommon for the two injuries to coexist and in some cases, the
carotid artery damage is bilateral.9

DISCUSSION
Cycle powered rickshaws have been part of the Edinburgh
scene for the past five or six years. Propelled—and
patronised—by students they provide a popular “taxi” service
along the pedestrianised zones in the capital centre. The occupant sits close to the ground and fairly close to the wire spokes
of the rickshaw wheels. Though at first the Edinburgh
accident was thought to be a rare unfortunate mishap, similar
cases in India have been discovered in the literature and this
raises the need for preventative measures to be introduced to
avoid further occurrence. Rickshaws now in use in Edinburgh
have plastic guards fitted to their wheels (fig 3).
This case raises several important points. The first is the
obvious difficulty in diagnosing cardiorespiratory arrest in the
presence of cervical oedema10 obscuring the carotid pulses.
Initial indications at the scene (and later at hospital) were of a
dismal prognosis. However, the attending ambulance crew,
encouraged by occasional movements of the patient and an
ECG rhythm that was potentially compatible with cardiac
output, made vigorous attempts at resuscitation concentrating
on basic airway care, ventilation, and oxygenation. The short
response, scene and transit times (a total prehospital time of
16 minutes) ensured that hypoxia did not become
established—and the initial SPO2 of 99% on arrival at hospital
was indeed very gratifying.
Secondly, of note was the impossibility of tracheal
intubation in this patient even with the assistance of

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Figure 3 Protected spokes on the wheel of a modern recreational
rickshaw.

anaesthetic agents. This was attributable to both the anatomical distortion of laryngeal structures and the secondary complication of facial and laryngeal oedema. Although it can be
speculated that there was a role for cricothyroidotomy at scene
it is noteworthy that even when it came to be performed this
procedure was not straightforward and required a specialist
approach.
The development of traumatic carotid artery stenosis is a
recognised complication of strangulation however it is of
interest there are occasions where this can be managed
conservatively with spontaneous recovery of the hemiparesis
recovered over time.
Finally, it is remarkable that this patient survived at all. We
can find no previous recorded evidence of survival from this
“syndrome”. The “take home” message from this case must be
that rapid intervention using good basic techniques in apparently hopeless cases can still occasionally produce remarkable
results.

ACKNOWLEDGEMENTS
Mr Paul Grant, ambulance technician who assisted in the management of the case. Ms Marianne Smith, librarian at the Royal College of
Surgeons for assistance with the literature search. Dr D Patel, consultant radiologist for assistance with the laryngeal imaging.
.....................

Authors’ affiliations
P A Gowens, A K Marsden, The Scottish Ambulance Service,
Edinburgh, UK
R J Davenport, Western General Hospital, Edinburgh, UK
J Kerr, R J Sanderson, Royal Infirmary of Edinburgh, UK
Conflict of interests: none.
Funding: none.
Correspondence to: Mr P A Gowens, The Scottish Ambulance Service,
Tipperlinn Road, Edinburgh EH10 5UU, UK; pgowens@scotamb.co.uk
Accepted for publication 7 August 2002

REFERENCES
1 Benecke M. Ungewollte Strangulation durch ein Fahrzeug: Der Tod von
Isadora Duncan. Rechstmedizin 1996;7:28–9.
2 Kohli A, Verma S, Agarwal B. Accidental strangulation in a rickshaw.
Forensic Sci Int 1996;82:191–92.
3 Aggarwal NK, Agarwal BB. Accidental strangulation in a cycle
rickshaw. Med Sci Law 1998;38:263–5.
4 Seed R. Traumatic injury to the larynx and trachea. Anaesthesia
1971;26:55.

Sodium bicarbonate for β blocker overdose
5 Blumenthal D, Riggs J, Ortiz O. Carotid artery occlusion following a
karate punch to the neck. Mil Med 1996;161:562–3.
6 Meairs S, Timpe L, Beyer J, et al. Acute aphasia and hemiplegia
following karate training. Lancet 2000;356:40.
7 Hughes P. Internal carotid artery occlusion following sports diving. J R
Nav Med Serv 2000;86:120–2.
8 Parenti G, Orlandi G, Bianchini M, et al. Vertebral and carotid artery

393
dissection following chiropractic cervical manipulation. Neurosurg Rev
1990;22:127–9.
9 Maier W. Diagnostic and therapeutic management of bilateral carotid
artery occlusion caused by near-suicidal hanging. Ann Otol Rhinol
Laryngol 1999;108:189–92.
10 Eberle B, Dick WF, Schneider T, et al. Checking the carotid pulse:
diagnostic accuracy of first responders in patients with and without a
pulse. Resuscitation 1996;33:107–16.

Sodium bicarbonate to treat massive β blocker overdose
U R Shanker, J Webb, A Kotze
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Emerg Med J 2003;20:393

S

odium bicarbonate is well recognised in the treatment of
tricyclic overdose. But its use in the treatment of massive
β blocker (propanol) overdose has not been previously
reported.

CASE REPORT
A 24 year old woman presented to the accident and emergency
department with a history of overdose, taking 92 propanolol
LA 80 mg, 45 paroxetine 30 mg, and 28 diazepam 5 mg tablets,
two hours before admission. NPIS advised us to give activated
charcoal every four hours and monitor vital signs closely and
if needed intravenous glucagon. Within 30 minutes of arrival
however her Glasgow Coma Score deteriorated rapidly and she
developed hypotension. Arterial blood gas measurements
showed metabolic and lactic acidosis. She rapidly deteriorated
and went into cardiorespiratory arrest. She was intubated and
standard ALS guidelines were followed. In addition NPIS was
contacted and advised the following—(1) 100 µl of 8.4%
sodium bicarbonate to correct the acidosis, (2) an isoprenaline
infusion to increase the heart rate, (3) an adrenaline
(epinephrine) infusion to increase the blood pressure, (4) glucagon infusion to bypass the β block and act directly on cyclic
GMP,1 (5) intravenous fluids to ensure adequate filling.
Despite this, the patient continued to have intermittent
arrests, principally PEA (5 PEA, 1VT, 1VF). The ECG trace
showed marked widening of QRS complex. Periods of arrest
were getting longer and the interval between them shorter.
NPIS were contacted again and advised rapid correction of
arterial pH to 7.5. Thus a bolus of 300 ml of 8.4% sodium
bicarbonate was given. Cardiac output was restored and the

ECG returned to a narrow complex morphology with sodium
of 150 mmol. She was transferred to the intensive care unit
and made a full recovery.
Propanolol is the most potent sodium channel blocker
among β blockers. Sodium channels play an important part in
the development of action potential in the cardiac muscle.
Bradycardia caused by β blocker overdose in normal hearts is
sodium channel block rather than β block.2 3 Treating β blocker
overdose with low extracellular K+ and high extracellular Na+
increased the heart rate and restored the ability to pace
thereby reversing the toxicity in isolated rat hearts.4 Similar
experiments have been made with dogs but there are no
reports of such treatment reported in humans. This is the first
reported case demonstrating the importance of overloading
sodium to counteract the block of the channels by β blocker
overdose.
.....................

Authors’ affiliations

REFERENCES
1 Smith RC, Wilkinson J, Hull RL. Glucagon for propanolol overdose.
JAMA 1985;254:2412.
2 Lisenberg FS, Buimsolm A, Eisenberg ES, et al. Seizures and
intraventricular conduction defects in propanolol poisoning. Ann Intern
Med 1979;91:860–2.
3 Paul F, Kolecki PF, Curry SC. Poisoning by Na channel blocking agents.
Crit Care Clin 1997;13:829–48.
4 Kerns W, Ransom A, Tomaszewski C, et al. The effects of extracellualr
ions on beta blocker cardiotoxicity. Toxicol Appl Pharmacol
1996;37:P1–7.
5 Critchley JA, Lengar A. The management of acute poisoning due to beta
adrenoreceptor antagonist. Med Toxicol 1989;4:32–45.

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