In this article we present a case of fatal strangulation with playground equipment in a 4-year-old child and a review of the literature. Playground injuries are a major cause of injury in children but fatalities are rare. However, strangulation is the cause of death in more than 50% of all playground fatalities. Neurological damage and death are caused by airway obstruction and venous congestion leading to hypoxia, acidosis, brain congestion and brain cell death. Airway injury in survivors is an exception and spinal cord injury has not been found in survivors. The mortality rate in strangulation is high. In cardiac arrest survival is unlikely and full neurological recovery has never been reported. However, all resuscitative efforts should be undertaken in patients with a residual circulation because neurologically intact survival is possible even in deeply comatose patients.