Choking

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Definition

Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut.

Description

Choking is a medical emergency. When a person is choking, air cannot reach the lungs. If the airways cannot be cleared, death follows rapidly.

Anyone can choke, but choking is more common in children than in adults. Choking is a common cause of accidental death in young children who are apt to put toys or coins in their mouths, then unintentionally inhale them. About 3,000 adults die each year from choking on food.

People also choke because infection causes the throat tissue to swell shut. It is believed that this is what caused George Washington's death. Allergic reactions can also cause the throat to swell shut. Acute allergic reactions are called anaphylactic reactions and may be fatal. Strangulation puts external pressure on the trachea causing another form of choking.

Finally, people can choke from obstructive sleep apnea. This is a condition where tissues of the body obstruct the airways during sleep. Sleep apnea is most common in obese men who sleep on their backs. Smoking, heavy alcohol use, lung diseases such as emphysema, and an inherited tendency toward a narrowed airway and throat all increase the risk of choking during sleep.

— Tish Davidson

Dictionary: chok·ing  (chō'kĭng)

1. Causing a feeling of being choked or suffocated: The hall was filled with choking clouds of smoke.
2. Having a strained or husky sound: spoke in a choking voice.

1. Difficulty in breathing because of blockage or partial blockage of the airway. Choking may have internal causes, such as emotional distress, as well as external causes, such as a direct blow to the throat.

2. Colloquially applied to athletes whose performance deteriorates under stress. Such athletes may feel as if they are physically choking because of tightening of the bronchial muscles around the airway. An athlete who chokes may be one who, through poor pacing or excessive enthusiasm, makes too much effort too early in a competition (e.g. a runner may go off too fast at the start of a race). The resulting accumulation of lactic acid induces hyperventilation and an uncomfortable tightening of the airway. The fear of competition may also induce excessive hyperventilation.

Definition

Choking is a condition caused by inhalation of a foreign object that partially or fully blocks the airway.

Description

Choking is a major cause of respiratory emergencies and cardiac arrest in infants and children. Choking occurs when a foreign object, such as food, buttons, coins, or toy parts, are inhaled and partially or completely block the airway, preventing adequate breathing. In many cases of choking, particularly in adults, the individual actively coughs and is able to expel the foreign object with no assistance or medical attention. However, children and infants are at increased risk of choking and foreign body airway obstruction due to immature airway and dental anatomy, distraction and play during eating, and a natural tendency to put objects into their mouths.

A 1995 study of the characteristics of objects known to commonly cause choking deaths in children found that round objects are most dangerous. For example, a small ball or marble can completely seal a child's or infant's trachea (windpipe). Round or cylindrical foods, hard candy, chewing gum, and balloons also present choking hazards. In infants, choking usually results from inhalation of small objects (coins, small toys, deflated balloons, buttons) that they place in their mouths.

Demographics

Each year, more than 17,000 infants and children are treated in hospital emergency departments for choking-related incidents, and more than 80 percent of these occur in children aged four years and younger. Airway obstruction death and injury are especially prevalent in children under age four due to anatomy (small airway), natural curiosity and tendency to put objects in their mouths, and incomplete chewing. According to statistics from the Centers for Disease Control and Prevention, choking rates in 2001 were highest in infants.

Causes and Symptoms

Choking is a major cause of death for children under three and is a hazard for older children as well. Young children naturally explore the world with their mouths, and they will readily put in their mouths anything that fits. If a small object slips back into the throat and blocks the trachea, the child may become unable to breathe, and unless the child is helped to eject the object quickly, the child may asphyxiate and die. Food is also a choking hazard, especially for children under three who do not know how to chew food thoroughly.

According to statistics from the Centers for Disease Control and Prevention, of the 17,000 or so cases of pediatric choking in 2001, 60 percent were related to food, 31 percent were related to non-food substances, and 9 percent were related to undetermined objects. Of the food-related choking incidents, 19 percent resulted from candy or gum. Of the choking incidents resulting from non-food objects, 13 percent were related to coins.

Food-related choking usually occurs because infants and young children do not chew their food well, and larger pieces can become stuck in their throat. The following foods have been identified by the American Academy of Pediatrics as presenting choking hazards:

• hot dogs
• hard candy
• chewing gum
• nuts and seeds
• chunks of meat or cheese
• whole grapes
• popcorn
• chunks of peanut butter
• raw vegetables
• raisins

The following objects have been identified as presenting choking hazards:

• coins
• buttons
• marbles
• small balls
• deflated balloons
• watch batteries
• jewelry
• ball point pen caps and paper clips
• arts and crafts supplies
• small toys and toys with small detachable parts

When to Call the Doctor

All infants, children, and adolescents who have a choking incident should see a doctor, since complications can occur even if the object causing the choking is successfully expelled. Sometimes, pieces can be aspirated into the lungs, and even though breathing returns to normal, wheezing, chest pain, persistent cough, and pneumonia can develop within a few days due to the foreign body in the lung. Foreign bodies may require removal by bronchoscopy or surgery.

Vomiting may occur after being treated with the Heimlich maneuver. All infants and children who experience a choking episode severe enough to require the Heimlich maneuver should be taken to the hospital emergency room to be examined for airway injuries.

Diagnosis

Choking is diagnosed by observation of the choking victim. Children able to actively cough should be watched to make sure they expel the object on their own and that their airways do not become blocked. Indications that a choking victim's airway is blocked include the following:

• inability to cough, cry, or speak
• blue or purple face color from lack of oxygen
• grabbing at throat
• weak cough and labored breathing that produces a high-pitched noise
• all of the above, followed by loss of consciousness

When the actual choking incident is not observed, choking can be diagnosed by observing the above symptoms. For children, infants, and adolescents who are unconscious, choking and foreign body obstruction can be diagnosed by attempting to give rescue breaths. If a breath administered to the victim does not inflate the chest, rescuers should assume that the airway is blocked and take steps to clear the airway.

Treatment

An emergency choking incident is treated using the Heimlich maneuver, usually administered by parents, caregivers and teachers, or bystanders. Children who have a choking incident that requires the Heimlich maneuver should be examined by a physician for potential injuries to their airway and aftereffects of oxygen deprivation.

The Heimlich maneuver is used when a child is choking on a foreign object to the extent that he/she cannot breathe. Oxygen deprivation from a foreign body airway obstruction can result in permanent brain damage or death in four minutes or less. Using the Heimlich maneuver can save a choking victim's life. The Heimlich maneuver is not performed on infants under one year of age; rather, a series of back blows and chest thrusts are used to attempt to dislodge the foreign object.

If the foreign body cannot be expelled from the child's airway using the Heimlich maneuver, cardiac and/or respiratory arrest may occur, and the child may stop breathing. If this happens, cardiopulmonary resuscitation (CPR) is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. CPR can be performed by trained laypeople or healthcare professionals on infants, children, adolescents, and adults. CPR should be performed if an infant, child, or adolescent is unconscious and not breathing.

Prognosis

Incorrectly applied, the Heimlich maneuver can break bones or damage internal organs. Following the Heimlich maneuver, dysphagia (swallowing difficulty) and obstructive pulmonary edema (fluid accumulation in the lungs) may occur and require medical treatment.

In many cases the foreign material is dislodged from the throat, and the choking victim suffers no permanent effects of the episode. If the foreign material is not removed, the choking victim may suffer permanent brain damage from lack of oxygen or may die.

Prevention

Choking is easily preventable by taking the following steps:

• supervising infants and children while they eat and play
• childproofing play areas by removing small objects
• cutting foods into very small pieces
• avoiding serving foods listed above as choking hazards to children under age four
• monitoring older children to make sure they do not give younger children hazardous foods or objects
• following age and safety guidelines on toys
• learning CPR and the Heimlich maneuver
• not letting children and infants play with coins

Parental Concerns

Because most choking incidents occur in the home, all parents and infant/child caregivers should be trained in the Heimlich maneuver. Training is available through the American Red Cross and American Heart Association at local schools, YMCAs, and community centers.

The likelihood of choking incidents can be reduced by closely supervising infants and children while they eat and play. Most choking incidents are associated with food items, especially hot dogs, candies, grapes, nuts, popcorn, and carrots. Common non-food items that present choking hazards include deflated balloons, buttons, coins, small balls, small toys, and toy parts. All toys should be examined to make sure they are age-appropriate and do not have loose parts.

Resources

Books

Basic Life Support for Healthcare Providers. Dallas, TX: American Heart Association, 2001.

Periodicals

Centers for Disease Control and Prevention. "Nonfatal Choking-Related Episodes among Children—United States, 2001." Journal of the American Medical Association 288 (November 20, 2002): 2400–02.

Vikle, Gary M., et al. "Airway Obstruction in Children Aged Less than Five Years: The Prehospital Experience." Prehospital Emergency Care 8 (2004): 196–99.

Organizations

American Heart Association. 7320 Greenville Ave., Dallas, TX 75231. Web site: www.americanheart.org.

The Heimlich Institute. 311 Straight St., Cincinnati, OH 45219–9957. Web site: www.heimlichinstitute.org.

Web Sites

"Choking Episodes among Children." National Center for Injury Prevention and Control. Available online at www.cdc.gov/ncipc/duip/spotlite/choking.htm (accessed December 8, 2004).

"Heimlich Maneuver." American Heart Association, 2004. Available online at www.americanheart.org/presenter.jhtml?identifier=4605 (accessed December 8, 2004).

"Infant First Aid for Choking and CPR: An Illustrated Guide." BabyCenter, 2004. Available online at www.babycenter.com/general/9298.html (accessed December 8, 2004).

National Safe Kids Campaign. Available online at www.safekids.org (accessed December 8, 2004).

[Article by: Jennifer E. Sisk, M.A.]

1. Difficulty in breathing due to any interference of the airway causing partial or complete blockage. The condition may be due to internal causes, such as emotional disturbance or external causes, such as a direct blow to the throat.

2. Colloquially applied to athletes whose performance deteriorates under stress, such as before an important competition. Such athletes may feel as if they are physically choking because their bronchial muscles tighten. An athlete who chokes may be one who, through poor pacing or excessive enthusiasm, develops a significant anaerobic effort too early in a competition. Consequently, the accumulation of lactic acid induces hyperventilation and an uncomfortable tightening of the airway. Alternatively, the fear of competition may induce excessive hyperventilation.

Pertaining to choke. Used to describe a syndrome in horses with dorsal soft palate displacement. A clinical sign of laryngeal disease.

Choking
Classification & external resources

ICD-10	F41.0, R06.8, T17, W78-W80
ICD-9	784.9, 933.1

For choking meaning compression of the neck, see Strangling. For other usage of choking, see choke. 'Chocking' redirects here, for the mechanical tool see Wheel chock

Choking is the mechanical obstruction of the flow of air from the environment into the lungs. Choking prevents breathing, and can be partial or complete, with partial choking allowing some, although inadequate, flow of air into the lungs. Prolonged or complete choking results in asphyxiation which leads to hypoxia and is potentially fatal.

Choking can be caused by:

• Introduction of a foreign object into the airway, which becomes lodged in the pharynx, larynx or trachea.
• Respiratory diseases that involve obstruction of the airway.
• Compression of the laryngopharynx, larynx or trachea in strangles.

Foreign objects

The type of choking most commonly recognised as such by the public is the lodging of foreign objects in the airway. This type of choking is often suffered by small children, who are unable to appreciate the hazard inherent in putting small objects in their mouth. In adults, it mostly occurs whilst the patient is eating.

Symptoms and Clinical Signs

• The person cannot speak or cry out.
• The person's face turns blue (cyanosis) from lack of oxygen.
• The person desperately grabs at his or her throat.
• The person has a weak cough, and labored breathing produces a high-pitched noise.
• The person does any or all of the above, and then becomes unconscious.

Treatment

Choking can be treated with a number of different procedures, with both basic techniques available for first aiders and more advanced techniques available for health professionals.

Many members of the public associate abdominal thrusts, also known as the 'Heimlich Manoeuvre' with the correct procedure for choking, which is partly due to the widespread use of this technique in movies, which in turn was based on the widespread adoption of this technique in the USA at the time, although it also produced easy material for writers to create comedy effect.

Most modern protocols (including those of the American Heart Association and the American Red Cross, who changed policy in 2006^[1] from recommending only abdominal thrusts) involve several stages, designed to apply increasingly more pressure.

The key stages in most modern protocols include:

Encouraging the victim to cough

This stage was introduced in many protocols as it was found that many people were too quick to undertake potentially dangerous interventions, such as abdominal thrusts, for items which could have been dislodged without intervention.

Back slaps

The majority of protocols now advocate the use of hard blows with the heel of the hand on the upper back of the victim. The number to be used varies by training organisation, but is usually between 5 and 20.

The back slap is designed to use percussion to create pressure behind the blockage, assisting the patient in dislodging the article. In some cases the physical vibration of the action may also be enough to cause movement of the article sufficient to allow clearance of the airway.

Almost all protocols give back slaps as a technique to be used prior to the consideration of potentially damaging interventions such as Abdominal thrusts^[2][3]

Abdominal thrusts

A demonstration of abdominal thrusts

Abdominal thrusts, also known as the Heimlich Maneuver (after Henry Heimlich, who first described the procedure in a June 1974 informal article entitled "Pop Goes the Cafe Coronary," published in the journal Emergency Medicine. Edward A. Patrick, MD, PhD, an associate of Heimlich, has claimed to be the uncredited co-developer of the procedure, and has been quoted calling it the Patrick maneuver.^[4] Heimlich has objected to the name "abdominal thrusts" on the grounds that the vagueness of the term "abdomen" could cause the rescuer to exert force at the wrong site.^[5]

Performing abdominal thrusts involves a rescuer standing behind a patient and using their hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it. This amounts to an artificial cough.

Due to the forceful nature of the procedure, even when done correctly it can injure the person on whom it is performed. Bruising to the abdomen is highly likely and more serious injuries can occur, including fracture of the xiphoid process or ribs.^[6]

Self treatment with abdominal thrusts

A person may also perform abdominal thrusts on themselves by using a fixed object such as a railing or the back of a chair to apply pressure where a rescuers hands would normally do so. As with other forms of the procedure, it is likely that internal injuries may result.

Other uses of abdominal thrusts

Dr. Heimlich also advocates the use of the technique as a treatment for drowning^[7] and asthma^[8] attacks, but Heimlich's promotion to use the maneuver to treat these conditions resulted in marginal acceptance. Criticism of these uses has been the subject of numerous print and television reports which resulted from an internet and media campaign by his son, Peter M. Heimlich, who alleges that in August 1974 his father published the first of a series of fraudulent case reports in order to promote the use of abdominal thrusts for near-drowning rescue.^[9]

Modified chest thrusts

A modified version of the technique is sometimes taught for use with pregnant women and obese casualties. The rescuer places their hand in the center of the chest to compress, rather than in the abdomen.

CPR

In most protocols, once the patient has become unconscious, the emphasis switches to performing CPR, involving both chest compressions and artificial respiration. These actions are often enough to dislodge the item sufficiently for air to pass it, allowing gaseous exchange in the lungs.

Finger Sweeping

Some protocols advocate the use of the rescuer's finger to 'sweep' foreign objects away once they have reached the mouth. However, many modern protocols recommend against the use of the finger sweep as if the patient is conscious, they will be able to remove themselves, or if they are unconscious the rescuer should simply place them in the recovery position (where the object should fall out due to gravity). There is also a risk of causing further damage (for instance inducing vomiting) by using a finger sweep technique.

Direct vision removal

The advanced medical procedure to remove such objects is inspection of the airway with a laryngoscope or bronchoscope, and removal of the object under direct vision, followed by CPR if the patient does not start breathing on their own. Severe cases where there is an inability to remove the object may require cricothyrotomy.

Notable victims

• United States President George W. Bush survived choking on a pretzel on January 13, 2002, receiving major media coverage.^[10]
• Jimmie Foxx, a famous major league baseball player, died by choking on a bone.^[11]
• Tennessee Williams, died after choking on a bottle cap.^[12]
• Mama Cass did not choke to death on a ham sandwich. It is an urban myth born out of a quickly discarded speculation by the coroner, who noted a part eaten ham sandwich and figured she may have choked to death. In fact, she died of heart failure.^[13]

References

1. ^ Red Cross press release on the move from abdominal thrusts only to an integrated protocol
2. ^ Guildner MD, Charles (September 1976). Abstract of Article on the Heimlich Maneuver. Retrieved on 2007-06-05.
3. ^ Article on chest compressions versus abdominal thrusts (Apr 2000). Retrieved on 2006-06-05.
4. ^ Patrick Institute. Retrieved on 2007-06-05.
5. ^
6. ^ Broomfield, James (1st January 2007). Heimlich maneuver on self. Discovery Channel. Retrieved on 2007-06-15.
7. ^ Heimlich Institute on rescuing drowning victims. Retrieved on 2007-06-05.
8. ^ Heimlich Institute on rescuing asthma victims. Retrieved on 2007-06-05.
9. ^ Heimlich, Peter M. 'Outmaneuvered - How We Busted the Heimlich Medical Frauds'. Retrieved on 2007-06-22.
10. ^ "Bush makes light of pretzel scare", BBC News, 14th Jan 2002. Retrieved on 2007-06-15. 
11. ^ Jimmie Foxx Obituary. Retrieved on 2007-06-15.
12. ^ Biography of Tennessee Williams. IMDB. Retrieved on 2007-06-15.
13. ^ Urband Legend of Mama Cass choking. Snopes Urban Legend Reference. Retrieved on 2007-06-15.

External links

Wikibooks First Aid has a page on the topic of

Abdominal thrusts

• Choking. (PDF Format). Contains further information on preventing choking in small children.
• Choking. Contains information on procedures to alleviate choking in different cases.
• [1][2]
• Emedicinehealth. Choking. www.emedicinehealth.com. URL last accessed March 6 2005.
• UK Resuscitation Council. Adult Basic Life Support. www.resus.org. URL last accessed February 28 2005.
• The Heimlich Institute
• Articles and information about Dr. Henry Heimlich's use of fraudulent case reports to promote the Heimlich maneuver for drowning rescue and asthma.

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