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Gregory H. Gilbert

Choking emergencies are important in EMS because of their time‐sensitive nature. Victims of choking can rapidly progress from airway obstruction to loss of consciousness and cardiac arrest. Bystanders must act quickly to resolve true choking episodes. EMS personnel will likely arrive on scene several minutes after the onset of choking. Therefore, they must be prepared to manage a patient in advanced stages of crisis. Choking is an emergency that must be solved on scene; there is limited value in bringing an unresolved choking victim to the emergency department for definitive treatment [1].

Choking results from obstruction of the trachea by a foreign object. It is the nature of the so‐called “café coronary” that occurs during or shortly after a meal [2]. Although most choking episodes are associated with food, nonedible objects may also cause airway occlusion, particularly in children who may inadvertently aspirate coins, toys, or other objects. Choking can occur with liquids as well as solid substances [3].

Although most obstructions occur in the hypopharynx, a small foreign body may lodge in either bronchus, causing selective obstruction of a lung or lung segment. Because the right bronchus travels more directly off the trachea, most selective obstructions involve the right lung. These tend to be nonfatal and are much more common in the pediatric population ( Table 24.1) [4].

Choking may be classified as partial or complete. A complete obstruction impairs the ability to breathe, to talk, and to cough and is an immediate life threat. A partial obstruction results in incomplete occlusion of the airway. In these instances, the individual may still be able to breathe, talk, or cough. A complete occlusion generally mandates immediate intervention such as the Heimlich maneuver, or direct laryngoscopy if ALS personnel are present. Other less invasive maneuvers may be appropriate in individuals with partial obstruction. However, in instances of partial obstruction with compromised air exchange, cyanosis, or loss of consciousness, the rescuer must approach the case as though it involves a complete airway obstruction [5].

The incidence of choking varies with age. For pediatrics, the majority are witnessed by the caregiver. While most of the 12,435 annual ED visits for pediatric choking episodes are nonfatal, there are approximately 175 deaths annually in the United States ( Figure 24.1). Children younger than 1 year of age are most likely to choke, with food and liquids causing most of these episodes. While food remains the most common and dangerous, toddlers ages 1 to 4 years have the highest incidence of choking on nonfood items such as coins, latex balloons, or toys. The U.S. Consumer Product Safety Commission has instituted monitoring systems, legislation, and regulations to protect children from nonfood items, but no similar interventions exist for preventing food‐related choking in children or adults. Hard candy, gum, nuts. and hot dogs are just some of the high‐risk foods [3–6].

Choking incidence rises again at age 60 years from concurrent conditions impairing chewing and coordinated swallowing (e.g., Alzheimer dementia, stroke, drinking alcohol, poor dentition, seizure, or Parkinson disease). A prior choking episode significantly increases the chances of future choking [2, 4, 7].

Reviewing the epidemiology of choking victims in these at‐risk groups provides valuable information. Japan found that 10% of fatal choking incidents came from mochi rice and 25% of those deaths occurred in a 3‐day window around the New Year [8]. Community education regarding this danger, coupled with first aid and CPR training for the community and caregivers, led to fewer choking deaths in subsequent years [9].

Table 24.1 Ten leading causes of nonfatal injury emergency department visits 2001–2018

Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Figure 24.1 Proportions of unintentional injury deaths in the United States 2001‐2018. Unintentional suffocation, including choking, is the fourth leading cause of death from unintentional injury for all age groups.