A 12-year-old girl was brought to the pediatric emergency department by ambulance after her mother found her hanging from her bunk bed. The patient was resuscitated initially but died 5 days later after support was withdrawn. A sexual assault examination was performed, and the finding was negative. The case was investigated as a possible homicide or suicide. Upon questioning relatives, it was disclosed that the deceased had played the choking game. No one knew she had been playing the game alone. The choking game is popular with adolescents and is particularly dangerous when played alone. Emergency physicians should be aware of the characteristic warning signs that include frequent severe headaches, altered mental status after spending time alone, neck markings, and bloodshot eyes and counsel adolescents about the real risks associated with the activity. Accident, suicide, homicide, autoerotic behavior, and the "choking game" should be considered in the differential when an adolescent presents with evidence of strangulation.