Internal Examination Choking

There may be no indication of a foreign body in the airway until the autopsy (334,350,377). If a foreign body is found, then inquiries must be made about the circumstances of the death. An "innocent" explanation about the presence of the foreign

Fig. 58. Choking. Piece of pork chop removed from larynx at autopsy. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

body may be elicited (e.g., placement of a coin at time of death as part of a traditional Chinese funeral practice [378]). Alternatively, the obstructing object is visualized during intubation but then is removed and not available for the pathologist to examine (114,355). Inquiry about any resuscitative efforts must be done. If resuscitation occurred and an artificial airway was inserted into the mouth, artifactual dislodgement of foreign material further into the pharynx may result (see Fig. 56 and refs. 355 and 360). Insertion of an endotracheal tube pushes a foreign body deeper into the larynx, trachea, mainstem bronchi, and esophagus. Failure to remove the larynx and inspect the oropharynx at autopsy means missing a cause of sudden death (335,369,379).

The level of obstruction depends on the dimensions of the foreign body and its relation to the age and airway size of the victim (333,334). Some examples of nonfood items described in adults are dental or medical appliances, nasal secretions, talcum powder, hardware, feces, medications, and diagnostic media (e.g., barium [341,345,350, 356,357,363,380-382]). The foreign body can be radiopaque (360). Children can choke on various items: balloons, small toys, hardware, coins, and the like (114,334, 344,346,383-385). Children choke more commonly on food (336). The food items are usually round and firm, yet pliable to allow molding in the airway (114,333,347,349). Items such as beans can swell (379). Many types of food have caused choking in children (e.g., hot dog, bread, rice, candy, nuts, gum, fruits, vegetables [114,334,337, 344,347,383]). In adults, meat and vegetable matter, animal bones, and whole fish have caused choking (Fig. 58; refs. 341,355,356, and 386). Softer foods are seen in institutionalized patients who have choked (355).

Epiglottic congestion, laryngeal mucosal hemorrhage, congestion, and petechiae have been described in choking cases (334,350,360). In children and adults, aspiration of hot liquid leads to epiglottic, laryngeal, and tracheal edema, and mucosal denudation requiring assisted ventilation (343,387,388).

Underlying disease predisposing to choking or aspiration should be assessed (340,389).

Sharp foreign bodies (e.g., bones, toothpicks) can be inadvertently swallowed with food. Deliberate swallowing of foreign bodies leading to airway obstruction does occur in the mentally handicapped, individuals with psychiatric disorders, prisoners, and criminals who are smuggling contraband (e.g., jewelry, drugs [390]). Some swallowed objects can remain in or penetrate the gastrointestinal tract (e.g., open safety pin in esophagus puncturing heart leading to hemopericardium, toothpick through small bowel into common iliac artery, bone penetrating esophagus into aorta or common carotid artery, wood screw in retroperitoneum with septicemia, coin impacted in esophagus compressing adjacent trachea [337,379,391-394]).

The Heimlich maneuver—i.e., the application of abdominal pressure to relieve the obstruction—can be associated with complications (353).

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