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    Choking: Symptoms, Causes, Complications And First Aid

    Choking is also termed as foreign body airway obstruction. It is the blockage of the upper airway due to food or other objects that prevents an individual from breathing efficaciously. Choking is a life-threatening medical emergency and most commonly occurs when a piece of food, an object, or a liquid becomes lodged in the throat [1] . In adults, it usually occurs as a result of breathing in fumes or eating or drinking too rapidly, and children choke as a result of placing any foreign objects in their mouths [2] .

    choking

    On a single glance, choking may not seem like a severe medical condition as we all have experienced it on any normal day. Although it is short-lived and non-dangerous usually, it can become life-threatening and pose critical complications. The mechanical obstruction tends to prevent normal breathing and can be partial (allowing some air passage into the lungs) or complete (no air passage into the lungs) [3] . The lack of oxygen can result in asphyxia, affecting your tissue and organs.

    According to Injury Facts 2017, choking is the fourth leading cause of unintentional injury death [4] . Out of the 5051 deaths reported from choking, 2848 were individuals older than 74. This suggests that death by choking is commonly reported in older individuals, with food being the responsible factor. In the same line, it is also a major cause of death in children under 1-year-old[3] .

    Symptoms Of Choking

    If an individual's upper airway is blocked, the following will be the signs [5] ,[6] .

    • Difficulty or inability to speak
    • Sudden panic
    • Laboured breathing, including gasping or wheezing may be present
    • Squeaky sounds when trying to breathe
    • Weak or forceful coughing 
    • Flushed skin which can turn pale or bluish in colour
    • Loss of consciousness
    • Violently gagging
    • The individual may begin clutching of the throat or mouth

    If an infant is choking, immediate help has to be orchestrated. Because an infant may not be aware of the situation and can result in dangerous complications [5] . And the signs are as follows:

    • Difficulty breathing
    • Weak cry and coughing
    Source: NY Times

    Causes Of Choking

    When your airway is blocked due to a piece of food or any other object, it can develop choking - which in some cases can be fatal. In adults, choking mostly occurs when the food is not chewed properly. The causes of choking can be classified into mechanical, neurological, musculoskeletal, immunologic and infectious [7]  [8] .

    Mechanical: These can occur as a result of not eating carefully or by swallowing foreign objects. Taking large bites, speaking or laughing while eating, and eating too quickly can cause the food to go to the wrong point and block the airway. Foreign objects that are basically non-food objects when swallowed can fall down the trachea and cause choking [8] .

    Neurological: Any disorder in the brain or the nerves can hinder with the proper functioning of your muscles, such as the muscles in your throat and mouth. So, the presence of any neurological issues can cause choking.

    Musculoskeletal: Any weakness in the throat or mouth muscles can pose restriction and limitations while swallowing, which in turn results in choking[9] .

    Immunologic: Certain allergic reactions, such as the ones that can cause inflammation and swell in the back of the mouth can block airflow and cause the individual to choke [10] .

    Infectious: Infections can cause swelling in the back of the mouth which can block the airflow, resulting in the development of a choking sensation.

    In older adults, advancing age, poorly fitting dental work, and alcohol consumption are some of the major causes of choking.

    In adults, it is due to alcohol consumption or drug use, talking or laughing while chewing food and certain illnesses such as Parkinson's disease [11]  [12] .

    In children, it usually happens when they place any foreign objects in their mouth (non-food), due to eating quickly or laughing while eating. Some of the most common objects that children choke on are [13] :

    • candy,
    • peanuts,
    • whole grapes,
    • large pieces of fruit or vegetable,
    • popcorn,
    • pencil erasers,
    • small toy parts, and
    • small key chains.
    causes

    Complications Of Choking

    Although people tend to consider choking as being seemingly harmless, untreated or unattended cases can result in death. The complications risen by choking are as follows [14] :

    • Brain damage, if the body is deprived of air for three minutes.
    • Throat irritation and damage.
    • In severe cases, death will occur from asphyxiation if the breathing is not restored in six to eight minutes.

    First Aid For Choking

    If you find yourself or anyone around you choking due to a blockage in the airway, the first and foremost thing to do is black blows or the Heimlich manoeuvre [15]  [16] . Drinking water will also help if you feel like something is stuck in your throat as it will push the object down the oesophagus (do this only when the choking is minor with small coughs).

    The first thing to be done when someone is choking is to do the American Red Cross 'five-and-five' approach. The approach involves two methods that can be carried alternatively. Begin with the five back blows and then do the Heimlich manoeuvre (if the choking still persists). However, it is completely fine to use the Heimlich manoeuvre alone [17] . Do not use these first-aid techniques if you are not well-practised. Make sure to call for help, before beginning with the first aid techniques [18] .

    1. Five back blows

    • Stand to the side and just behind the choking adult (For a child, kneel down behind). 
    • Place one arm across the person's chest for support [19]
    • Bend the person over at the waist so that the upper body is parallel with the ground.
    • Deliver five separate back blows between the person's shoulder blades with the heel of your hand.

    2. The Heimlich manoeuvre

    • Stand behind the person (For a child, kneel down behind).
    • Place one foot slightly in front of the other for balance. 
    • Wrap your arms around the waist (of the choking person).
    • Tip the person forward slightly [20]
    • Make a fist with one hand and position it slightly above the person's navel.
    • Grasp the fist with the other hand and, press hard into the abdomen with a quick, upward thrust (as if trying to lift the person up).
    • Perform between 6 and 10 abdominal thrusts, until the blockage is dislodged.
    heimlich

    However, it is not the case that someone will be around when a person chokes. If you are alone and choking, call for help immediately. And while waiting for help to arrive, you can perform the Heimlich manoeuvre on yourself [21] .

    • Place a fist slightly above your navel.
    • Grasp your fist with the other hand and bend over a hard surface, such as a chair. 
    • Shove your fist inward and upward.

    For an obese person

    • Position your hands a little bit higher than you usually follow in a normal Heimlich manoeuvre - at the base of the breastbone, just above the joining of the lowest ribs.
    • Proceed as with the manoeuvre, pressing hard into the chest with a quick thrust.
    • Repeat until the food or other blockage is dislodged.

    The same applies to pregnant women.

    For an unconscious person

    • Lower the person on her back onto the floor and arms to the side.
    • Clear the airway, that is, if a blockage is visible at the back of the throat reach a finger into the mouth and sweep; do not try this if you cannot see the blockage [21]
    • Start with cardiopulmonary resuscitation (CPR).

    For an infant younger than age 1

    • Take a seated position and hold the infant face down on your forearm, resting on your thigh.
    • Support the infant's head and neck with your hand, and place the head lower than the trunk.
    • Thump the infant gently but firmly five times on the middle of the back using the heel of your hand.
    • Keep your fingers pointed up to avoid hitting the infant in the back of the head.

    If the infant is still struggling, get him or her to the nearby hospital immediately [22] .

    3. Cardiopulmonary resuscitation (CPR)

    • Lay the person down on their back on a flat surface.
    • Kneel on the side of the unconscious person and place your hand (palm down) in the middle of their chest. 
    • Place your free hand over the top of the other [23] .
    • Lean forward with your shoulders and push down quickly, 100 times per minute.
    • Repeat this process until the person starts breathing again or until medical help gets there.
    CPR

    *Caution: Do not perform the five-and-five method on a child. Only do the above mentioned first aid methods if you are well-versed in it. Because even the slightest mistake can result in fatality.

    Treatments For Choking

    If the aforementioned methods and techniques do not provide any relief, you will be required to undergo the following [24]  [25] .

    • If the Heimlich manoeuvre or CPR does not provide the expected result, an inspection of the airway with a laryngoscope or bronchoscope will be carried out to remove the object under direct vision. 
    • In rare cases, surgery will be required. A cricothyrotomy or an emergency tracheostomy will be conducted by making an incision in the patient's neck and inserting a tube into the trachea so as to bypass the upper airways.
    View Article References
    1. [1] Baumeister, R. F. (1984). Choking under pressure: self-consciousness and paradoxical effects of incentives on skillful performance.Journal of personality and social psychology,46(3), 610.
    2. [2] Beilock, S. L., & Carr, T. H. (2001). On the fragility of skilled performance: What governs choking under pressure?.Journal of experimental psychology: General,130(4), 701.
    3. [3] Berzlanovich, A. M., Fazeny-Dörner, B., Waldhoer, T., Fasching, P., & Keil, W. (2005). Foreign body asphyxia: a preventable cause of death in the elderly.American journal of preventive medicine,28(1), 65-69.
    4. [4] Ruschena, D., Mullen, P. E., Palmer, S., Burgess, P., Cordner, S. M., Drummer, O. H., ... & Barry-Walsh, J. (2003). Choking deaths: the role of antipsychotic medication.The British Journal of Psychiatry,183(5), 446-450.
    5. [5] Egge, M. K., Berkowitz, C. D., Toms, C., & Sathyavagiswaran, L. (2010). The choking game: a cause of unintentional strangulation.Pediatric emergency care,26(3), 206-208.
    6. [6] Chang, C. Y., Cheng, T. J., Lin, C. Y., Chen, J. Y., Lu, T. H., & Kawachi, I. (2013). Reporting of aspiration pneumonia or choking as a cause of death in patients who died with stroke.Stroke,44(4), 1182-1185.
    7. [7] Wang, X., You, G., Chen, H., & Cai, X. (2002). Clinical course and cause of death in elderly patients with idiopathic Parkinson's disease.Chinese medical journal,115(9), 1409-1411.
    8. [8] Keene, J., Hope, T., Fairburn, C. G., & Jacoby, R. (2001). Death and dementia.International journal of geriatric psychiatry,16(10), 969-974.
    9. [9] Nixon, J. W., Kemp, A. M., Levene, S., & Sibert, J. R. (1995). Suffocation, choking, and strangulation in childhood in England and Wales: epidemiology and prevention.Archives of Disease in Childhood,72(1), 6-10.
    10. [10] Tarrago, S. B. (2000). Prevention of choking, strangulation, and suffocation in childhood.WMJ: official publication of the State Medical Society of Wisconsin,99(9), 43-6.
    11. [11] Sadovnick, A. D., Eisen, K., Ebers, G. C., & Paty, D. W. (1991). Cause of death in patients attending multiple sclerosis clinics.Neurology,41(8), 1193-1193.
    12. [12] American Academy of Pediatrics. (2010). Policy Statement--Prevention of Choking Among Children.Pediatrics,125(3), 601-607.
    13. [13] Baumeister, R. F., & Showers, C. J. (1986). A review of paradoxical performance effects: Choking under pressure in sports and mental tests.European Journal of Social Psychology,16(4), 361-383.
    14. [14] Committee on Injury, Violence, and Poison Prevention. (2010). Prevention of choking among children.Pediatrics,125(3), 601-607.
    15. [15] Shavelle, R. M., Strauss, D., Whyte, J., Day, S. M., & Yu, Y. L. (2001). Long-term causes of death after traumatic brain injury.American Journal of Physical Medicine & Rehabilitation,80(7), 510-516.
    16. [16] Spooner, F., Stem, B., & Test, D. W. (1989). Teaching first aid skills to adolescents who are moderately mentally handicapped.Education and Training in Mental Retardation, 341-351.
    17. [17] Heimlich, H. J. (1975). A life-saving maneuver to prevent food-choking.Jama,234(4), 398-401.
    18. [18] Anderson, G. S., Gaetz, M., & Masse, J. (2011). First aid skill retention of first responders within the workplace.Scandinavian journal of trauma, resuscitation and emergency medicine,19(1), 11.
    19. [19] Heimlich, H. J. (1982). First aid for choking children: back blows and chest thrusts cause complications and death.Pediatrics,70(1), 120-125.
    20. [20] Heimlich, H. J., & Patrick, E. A. (1990). The Heimlich maneuver: best technique for saving any choking victim's life.Postgraduate Medicine,87(6), 38-53.
    21. [21] Day, R. L., Crelin, E. S., & DuBois, A. B. (1982). Choking: the Heimlich abdominal thrust vs back blows: an approach to measurement of inertial and aerodynamic forces.Pediatrics,70(1), 113-119.
    22. [22] Kirshner, R. L., & Green, R. M. (1985). Acute thrombosis of abdominal aortic aneurysm subsequent to Heimlich maneuver: a case report.Journal of vascular surgery,2(4), 594-596.
    23. [23] Anderson, G. S., Gaetz, M., & Masse, J. (2011). First aid skill retention of first responders within the workplace.Scandinavian journal of trauma, resuscitation and emergency medicine,19(1), 11.
    24. [24] Chorpita, B. F., Vitali, A. E., & Barlow, D. H. (1997). Behavioral treatment of choking phobia in an adolescent: An experimental analysis.Journal of Behavior Therapy and Experimental Psychiatry,28(4), 307-315.
    25. [25] DAY, R. L. (1983). Differing opinions on the emergency treatment of choking.Pediatrics,71(6), 976-978.

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