Introduction: Hair tourniquet syndrome is a well-documented phenomenon in which hair can become tightly wrapped around an appendage resulting in ischemic injury and necrosis. When a hair tourniquet involves the neck as the appendage, fatality can result due to asphyxia, specifically strangulation. Strangulation can be fatal, and death can result within minutes. In the pediatric population, suffocation is a concern when assessing the sleep of newborns and infants. There are inherent dangers of co-sleeping that are routinely discussed during pediatric office visits, particularly about newborns. Parents are alerted to the risks of suffocation exist with overlay, wedging, chords near the bed, large plush stuffed animals, and heavy blankets and pillows. We present a case of accidental strangulation via hair tourniquet in a toddler who was found co-sleeping with his sister. Case Presentation: A nineteen-month-old male was brought into the emergency department via ambulance after an episode of apnea and cyanosis. On the night of admission, his parents awoke after they heard the patient’s sister screaming. The parents ran into the bedroom, where the patient and his five-year-old sister were co-sleeping, to find the patient cyanotic with loss of consciousness. EMS was immediately called and prior to arrival to the ED, the patient regained consciousness without intervention by EMS. Past medical history and family history were noncontributory. Vital signs upon presentation to the ED included temperature 97.9°F, heart rate 103-160 bpm, respiratory rate 26-34 bpm, and pulse oximetry of 96-98% on room air. On physical examination, a linear circumferential mark on the patient’s neck was noted as well as scattered petechiae on his cheeks bilaterally. Physical exam was otherwise unremarkable. Chest x-ray was normal and x-ray of his neck revealed hypopharyngeal dilatation. Liver enzymes were normal, AST 67 and ALT 15. Skeletal survey was normal, with no evidence of previous or acute fractures. Doppler studies of neck vasculature showed patent bilateral common carotid arteries and internal jugular vein, with no evidence of common carotid arterial dissection. Child protective services and law enforcement were notified given the patient’s near fatality. Upon investigation, the sister’s hair was confirmed to be at the level of the sacrum, with pieces of hair missing, which were found near the bed where the patient and his sister were sleeping. The case was deemed an accident and the patient was discharged home to his family. Discussion: Given the rare presentation in this case, it is essential to consider child abuse as a differential and involve law enforcement agents and/or child protective services to confirm scene investigation is consistent with the history provided to the medical team. Therefore, consultation by the child abuse pediatrician was initiated and a skeletal survey was performed, which was negative for additional injury.