Scene and Circumstances Accidental Choking Deaths The phases of acute fatal airway obstruction are

1. Penetration of the object into the airway.

2. Obstruction of the airway.

3. Failure to expel once the obstruction has occurred (333).

Witnesses of a sudden death may describe signs of acute upper airway (glottic) obstruction (stridor, respiratory distress, coughing, choking) and the inability of the victim to speak (334-337). A rapid, deep inhalation frequently follows, causing a foreign object to pass further down the airway (333,338). Laryngospasm occurs (338). At this point, vagal stimulation, leading to arrhythmia and apnea, is a possible mechanism of death (339). An allergic reaction, manifest as laryngeal mucosal edema, happens under some circumstances (e.g., aspiration of pepper [340]). In some cases of foreign body obstruction in the esophagus and lower tracheobronchial tree, there is an asymptomatic period prior to the onset of respiratory symptoms (coughing, wheezing, dyspnea [334,336,341,342]). When hot liquid is aspirated, the onset of symptoms (difficulty speaking, dyspnea) develops following a latent period, up to 8 h (343). Incomplete obstruction eventually becomes complete when respiratory tract mucosal edema, inflammation, hemorrhage and bronchospasm occur (334). Chronic symptoms can develop (see Subheading 3.5.).

Choking is a common cause of accidental death in children less than 1 yr of age (116,334,344). Ninety percent of choking deaths happen before the age of 5 yr. Various reviews have shown an age range of 4 mo to 14 yr (344). Older victims tend to be mentally challenged, but normal older children can choke (334). Children aged 1 to 3 yr are vulnerable to choking ("creche coronary") because of their increased mobility, inability to judge the appropriateness of placing small objects in their mouths and appreciate the size of a piece of food, small airways, inadequate dentition for chewing (i.e., development of incisors before molars allows biting but not proper mastication), and weaker cough reflex (116,333,336,337,342,345-348).

Home is the most common setting for incidents involving children (344). In many instances, the child is given an item by an adult who may not recognize the potential danger (344,349). The choking event is often unwitnessed (334). In one series, there was an adult present in about half the choking incidents, but direct supervision may have been lacking (333,344). Other children can distract supervising adults (e.g., in a day care center [347]).

Choking occurs while eating and playing (e.g., running [347]). Sampling of new foods can lead to choking (347). Pica syndrome is the ingestion of inappropriate material that occurs in children and adults (345). Mentally challenged individuals and people with neurological disorders can devour food ravenously (gluttony; see Fig. 56 and refs. 340 and 350). Children younger than 1 yr of age are more likely to aspirate food, whereas older children tend to choke on nonfood items (334,348). In very young children, the possibility of SIDS arises, but choking needs to be considered (334). Choking on a pacifier has been described (Fig. 57; refs. 114 and 351). Pacifier use was less frequent in SIDS cases than in controls in one study (352).

In adult cases, there is either a sudden collapse mimicking an apparent heart attack while eating ("café coronary") or the death is unwitnessed (334,335,350,353). Predisposing factors include a decreased protective airway reflex resulting from aging, poor dentition with a tendency to swallow food whole, alcohol consumption, and ingestion of other CNS depressants impairing the gag reflex (335,341,342,345,350,354,355). Only a third of fatalities happen in a restaurant (355). Most adult choking deaths occur

Fig. 56. Mentally challenged individual. Pica. Piece of plastic pushed down into carina by endotracheal tube. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

at home, in a nursing home, or in a psychiatric institution (350,355). Deaths have been described in hospitals (350). Long-term care patients may have an underlying neurological or psychiatric disorder, resulting in a decreased cough reflex or dysphagia (341,345, 350,355-358).

Other choking situations have been described. A bulimic individual can aspirate an object used to induce vomiting (e.g., fork [359]). Abnormal positions while eating can result in choking (350). Xerostomia (dry mouth) from salivary gland dysfunction causes swallowing difficulty (350). An emotional outburst can trigger a choking episode (360). A blow to the mouth, a seizure, or a loss of consciousness are other scenarios (360).

Fig. 57. Infant. Choking on pacifier. (A) Pacifier in mouth. (B) Anterior neck (larynx removed). Pacifier protruding through oropharynx.

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