Choking

Choking is a form of behavior due to 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:
 * Physical obstruction of the airway by a foreign body.
 * Respiratory diseases that involve obstruction of the airway.
 * Compression of the laryngopharynx, larynx or vertebrate trachea in strangulation.

Foreign objects
The type of choking most commonly recognized as such by the public is the lodging of foreign objects (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, peanuts 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 wheezing.
 * 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 (cyanosis) 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 aiders and more advanced techniques available for health professionals. In the United States, members of the public commonly assume that abdominal thrusts, also known as the Heimlich Maneuver, are the correct procedure for choking, due to widespread promotion of this technique in the past, including recommendations from the American Heart Association and the American Red Cross. People elsewhere also often assume this, due in part to widespread use of this technique in movies.

Most modern protocols, including those of the American Heart Association and the American Red Cross, recommend several stages, designed to apply increasingly more pressure. The Red Cross changed their recommendation in 2006, ending their promotion of abdominal thrusts as the primary treatment for choking.

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 of the action may also be enough to cause movement of the article sufficient to allow clearance of the airway.

Almost all protocols ( actually only the Red Cross promotes back slaps, The AHA does not promote back slapping, because if the person falls, they will fall on their face causing possible head injury to the face, jaw and neck injury) give back slaps as a technique to be used before potentially damaging interventions such as abdominal thrusts. Henry Heimlich, noted for promulgating abdominal thrusts, claimed that back slaps were proven to cause death by lodging foreign objects into the windpipe. The 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 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. 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 ribs.

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 obese patients. The rescuer places their hand in the center of the chest to compress, rather than in the abdomen.

Finger sweeping
The American Medical Association 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 since, 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.

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.

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.

Notable victims

 * United States President George W. Bush survived choking on a pretzel on January 13, 2002, receiving major media coverage.
 * Jimmie Foxx, a famous Major League Baseball player, died by choking on a bone.
 * Tennessee Williams, 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 coroner, 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 Mother 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 drowning 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.