Choking
Encyclopedia
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 asphyxia
which leads to anoxia
and is potentially fatal. Oxygen stored in the blood and lungs keep the victim alive for several minutes after breathing is stopped completely.
Choking can be caused by:
(also known as foreign bodies, but consisting of any object which comes from outside the body itself, including food, toys or household 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. In one study, peanut
s were the most common obstruction.
ers and more advanced techniques available for health professionals.
Many members of the public associate abdominal thrusts, also known as the Heimlich Maneuver 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 United States at the time.
Most modern protocols, including those of the American Heart Association and the American Red Cross, who changed policy in 2006 from recommending only abdominal thrusts) involve several stages, designed to apply increasingly more pressure.
The key stages in most modern protocols include:
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 before to the consideration of potentially damaging interventions such as abdominal thrusts, but Henry Heimlich, noted for promulgating abdominal thrusts, wrote in a letter to the New York Times that back slaps were proven to cause death by lodging foreign objects in to the windpipe.
The findings of a 1982 Yale study by Day, DuBois, and Crelin that "persuaded the American Heart Association to stop recommending back blows for dealing with choking...was partially funded by Heimlich's own foundation." According to Roger White MD of the Mayo Clinic and American Heart Association (AHA), "There was never any science here. Heimlich overpowered science all along the way with his slick tactics and intimidation, and everyone, including us at the AHA, caved in."
, 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. 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.
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 rib
s.
In some areas, such as Australia, authorities believe that there is not enough scientific evidence to support the use of Abdominal thrusts and their use is not recommended in first aid.
patients. The rescuer places their hand in the center of the chest to compress, rather than in the abdomen.
advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions, once the choking victim becomes unconscious.
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 the foreign object 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.
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
.
. These actions are often enough to dislodge the item sufficiently for air to pass it, allowing gaseous exchange in the lungs.
and asthma
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.
Asphyxia
Asphyxia or asphyxiation is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs...
which leads to anoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...
and is potentially fatal. Oxygen stored in the blood and lungs keep the victim alive for several minutes after breathing is stopped completely.
Choking can be caused by:
- Physical obstruction of the airway by a foreign bodyForeign bodyA foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
. - Respiratory diseaseRespiratory diseaseRespiratory disease is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange possible in higher organisms, and includes conditions of the upper respiratory tract, trachea, bronchi, bronchioles, alveoli, pleura and pleural cavity, and the...
s that involve obstruction of the airway. - Compression of the laryngopharynx, larynxLarynxThe larynx , commonly called the voice box, is an organ in the neck of amphibians, reptiles and mammals involved in breathing, sound production, and protecting the trachea against food aspiration. It manipulates pitch and volume...
or vertebrate tracheaVertebrate tracheaIn tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
in strangulation.
Foreign objects
The type of choking most commonly recognized as such by the public is the lodging of foreign objectsForeign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
(also known as foreign bodies, but consisting of any object which comes from outside the body itself, including food, toys or household objects) in the airway.
This type of choking is often suffered by small children, who are unable to appreciate the hazard
Hazard
A hazard is a situation that poses a level of threat to life, health, property, or environment. Most hazards are dormant or potential, with only a theoretical risk of harm; however, once a hazard becomes "active", it can create an emergency situation. A hazard does not exist when it is not...
inherent in putting small objects in their mouth. In adults, it mostly occurs whilst the patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
is eating. In one study, peanut
Peanut
The peanut, or groundnut , is a species in the legume or "bean" family , so it is not a nut. The peanut was probably first cultivated in the valleys of Peru. It is an annual herbaceous plant growing tall...
s were the most common obstruction.
Symptoms and clinical signs
- The person cannot speak or cry out, or has great difficulty and limited ability to do so.
- Breathing, if possible, is labored, producing gasping or wheezingWheezeA wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, or airflow velocity within the respiratory tree must be heightened...
. - The person has a violent and largely involuntary cough, gurgle, or vomiting noise, though more serious choking victims will have a limited (if any) ability to produce these symptoms since they require at least some air movement.
- The person desperately clutches his or her throat or mouth, or attempts to induce vomiting by putting their fingers down their throat.
- If breathing is not restored, the person's face turns blue (cyanosisCyanosisCyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
) from lack of oxygen. - The person does any or all of the above, and if breathing is not restored, then becomes unconscious.
Treatment
Choking can be treated with a number of different procedures, with both basic techniques available for first aidFirst aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...
ers and more advanced techniques available for health professionals.
Many members of the public associate abdominal thrusts, also known as the Heimlich Maneuver 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 United States at the time.
Most modern protocols, including those of the American Heart Association and the American Red Cross, who changed policy in 2006 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. Also, if the choking is caused by an irritating substance rather than an obstructing one, and if conscious, the patient should be allowed to drink water on their own to try to clear the throat. Since the airway is already closed, there is very little danger of water entering the lungs. Coughing is normal after most of the irritant has cleared, and at this point the patient will probably refuse any additional water for a short time.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 organization, but is usually between five and twenty.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
Vibration
Vibration refers to mechanical oscillations about an equilibrium point. The oscillations may be periodic such as the motion of a pendulum or random such as the movement of a tire on a gravel road.Vibration is occasionally "desirable"...
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 before to the consideration of potentially damaging interventions such as abdominal thrusts, but Henry Heimlich, noted for promulgating abdominal thrusts, wrote in a letter to the New York Times that back slaps were proven to cause death by lodging foreign objects in to the windpipe.
The findings of a 1982 Yale study by Day, DuBois, and Crelin that "persuaded the American Heart Association to stop recommending back blows for dealing with choking...was partially funded by Heimlich's own foundation." According to Roger White MD of the Mayo Clinic and American Heart Association (AHA), "There was never any science here. Heimlich overpowered science all along the way with his slick tactics and intimidation, and everyone, including us at the AHA, caved in."
Abdominal thrusts
Abdominal thrusts, also known by the proprietary name the Heimlich Maneuver (after Henry HeimlichHenry Heimlich
Dr. Henry Jay Heimlich , an American physician, has received credit as the inventor of abdominal thrusts, more commonly known as the Heimlich maneuver, though debate continues over his role in the development of the procedure...
, 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. 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.
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
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
, hopefully expelling it. This amounts to an artificial cough
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...
.
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
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
is highly likely and more serious injuries can occur, including fracture of the xiphoid process
Xiphoid process
The xiphoid process, or xiphisternum or metasternum, is a small cartilaginous process of the lower part of the sternum which is usually ossified in the adult human. By age 15 to 29, the xiphoid usually fuses to the body of the sternum with a fibrous joint. Unlike the synovial articulation of major...
or rib
Rib
In vertebrate anatomy, ribs are the long curved bones which form the rib cage. In most vertebrates, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the chest cavity. They serve to protect the lungs, heart, and other internal organs of the thorax...
s.
In some areas, such as Australia, authorities believe that there is not enough scientific evidence to support the use of Abdominal thrusts and their use is not recommended in first aid.
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 rescuer's hands would normally do so. As with other forms of the procedure, it is possible that internal injuries may result.Modified chest thrusts
A modified version of the technique is sometimes taught for use with pregnant and/or obeseObesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
patients. The rescuer places their hand in the center of the chest to compress, rather than in the abdomen.
Finger sweeping
The American Medical AssociationAmerican Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions, once the choking victim becomes unconscious.
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 the foreign object themselves, or if they are unconscious, the rescuer should simply place them in the recovery position
Recovery position
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in to which an unconscious but breathing casualty can be placed as part of first aid treatment.An unconscious person The recovery position refers to one of a series of...
(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 laryngoscopeLaryngoscope
Laryngoscopy is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper...
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
Cricothyrotomy
A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive...
.
CPR
In most protocols, once the patient has become unconscious, the emphasis switches to performing CPR, involving both chest compressions and artificial respirationArtificial respiration
Artificial respiration is the act of assisting or stimulating respiration, a metabolic process referring to the overall exchange of gases in the body by pulmonary ventilation, external respiration, and internal respiration...
. These actions are often enough to dislodge the item sufficiently for air to pass it, allowing gaseous exchange in the lungs.
Notable victims
- United States President George W. BushGeorge W. BushGeorge Walker Bush is an American politician who served as the 43rd President of the United States, from 2001 to 2009. Before that, he was the 46th Governor of Texas, having served from 1995 to 2000....
survived choking on a pretzelPretzelA pretzel is a type of baked food made from dough in soft and hard varieties and savory or sweet flavors in a unique knot-like shape, originating in Europe...
on January 13, 2002, receiving major media coverage. - Jimmie FoxxJimmie FoxxJames Emory "Jimmie" Foxx , nicknamed "Double X" and "The Beast", was a right-handed American Major League Baseball first baseman and noted power hitter....
, a famous Major League BaseballMajor League BaseballMajor League Baseball is the highest level of professional baseball in the United States and Canada, consisting of teams that play in the National League and the American League...
player, died by choking on a bone. - Tennessee WilliamsTennessee WilliamsThomas Lanier "Tennessee" Williams III was an American writer who worked principally as a playwright in the American theater. He also wrote short stories, novels, poetry, essays, screenplays and a volume of memoirs...
, the playwright, died after choking on a bottle cap. - An urban legend states that obese singer Mama Cass choked to death on a ham sandwich. This was borne out of a quickly discarded speculation by the coronerCoronerA coroner is a government official who* Investigates human deaths* Determines cause of death* Issues death certificates* Maintains death records* Responds to deaths in mass disasters* Identifies unknown dead* Other functions depending on local laws...
, who noted a partly eaten ham sandwich and figured she may have choked to death. In fact, she died of a heart condition, often wrongly referred to in the media as heart failure. - The Queen MotherElizabeth Bowes-LyonElizabeth Angela Marguerite Bowes-Lyon was the queen consort of King George VI from 1936 until her husband's death in 1952, after which she was known as Queen Elizabeth The Queen Mother, to avoid confusion with her daughter, Queen Elizabeth II...
was admitted to a UK Hospital for an operation in May 1993 after choking on a fish bone.
Other uses of abdominal thrusts
Dr. Heimlich also advocates the use of the technique as a treatment for drowningDrowning
Drowning is death from asphyxia due to suffocation caused by water entering the lungs and preventing the absorption of oxygen leading to cerebral hypoxia....
and asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
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.
External links
- NHS Choices Common Health Questions: What should I do if someone is choking?
- NHS Choices Common Health Questions: What should I do if a baby is choking?
- NHS Choices Birth to Five Planner: How to help a choking child