Why should we chock a patient
Evidence base
Choking, or foreign body airway obstruction, is a common, yet treatable, cause of accidental death (Fingerhut et al 1998, Baharloo et al 1999). Despite this, and a rise in public access resuscitation courses, national statistics suggest that accidental death as a result of choking is increasing. It was reported that 210 adults died as a result of choking in England and Wales in 2011 (Rogers 2011). However, since the majority of choking episodes occur when eating and drinking, the individual is often conscious at the outset and prompt action by those present can be life-saving (Perkins et al 2015).
Early recognition and prompt action is essential to optimise the chances of clearing the airway obstruction (Perkins et al 2015). Any adult may be at risk of foreign body airway obstruction when eating or drinking; however, altered conscious levels, intoxication and neurological disorders that impair swallowing reflexes increase the risk of choking and foreign body airway obstruction significantly (Wong and Tariq 2011). The severity of airway obstruction can be categorised as either mild or severe, and treatment varies depending on the level of severity (Perkins et al 2015).
Management
Mild obstruction: for a mild obstruction, in which the airway is partially obstructed, the person may be attempting to clear their airway by coughing. This should be encouraged, since coughing will create and maintain high airway pressures, which may be sufficient to expel the obstruction (Perkins et al 2015).
Severe obstruction: inappropriate delivery of back blows and abdominal thrusts has the potential to cause harm and could lead to worsening of the obstruction. Since severe obstruction can develop, it is essential to continuously observe the person (Perkins et al 2015).
The evidence which underpins treatment for severe foreign body airway obstruction is predominantly anecdotal and retrospective (Guildner et al 1976, Ruben and Macnaughton 1978, Perkins et al 2015). However, Redding (1979) established that using abdominal thrusts alone is unlikely to be effective. This is supported by current Resuscitation Council (UK) guidelines (Perkins et al 2015), which advocate an alternating pattern of back blows and abdominal thrusts.
Unconscious person: for a patient who is unconscious, it has been established that higher airway pressures are achieved with chest thrusts compared to abdominal thrusts (Guildner et al 1976, Ruben and Macnaughton 1978, Langhelle et al 2000). Rescuers should be encouraged to commence CPR when the person becomes unconscious.
Kinoshita et al (2015) studied the outcome of foreign body airway obstruction for people choking during meals, depending on the immediate action taken by rescuers. They established that commencing chest compressions when the person became unconscious resulted in significantly improved outcomes, and was associated with a positive neurological outcome. These recommendations form the basis of current resuscitation guidelines for the management of an unconscious choking person (Perkins et al 2015).
Aftercare: Perkins et al (2015) advise caution after treatment of foreign body airway obstruction. Residual foreign material may remain in either the upper or lower respiratory tract, and advised that adults who experience a persistent cough, difficulty in swallowing, or a sensation of an object stuck in their throat, should seek medical advice to rule out potential complications. Similarly, the vigour required to deliver back blows and abdominal thrusts may cause internal injury and medical advice should be sought after the event (Perkins et al 2015).
Learning points
- Any adult may be at risk of foreign body airway obstruction when eating or drinking; however, altered conscious levels, intoxication and neurological disorders that impair swallowing reflexes increase the risk of choking and airway obstruction.
- Residual foreign material may remain in either the upper or lower respiratory tract, and adults who experience a persistent cough, difficulty in swallowing, or a sensation of an object stuck in their throat, should seek medical advice to rule out potential complications.
- Vigour required to deliver back blows and abdominal thrusts may cause internal injury and medical advice should be sought after the event.
- Always follow current national/international resuscitation guidelines to manage a choking adult.
Disclaimer: Please note that information provided by RCNi Learning is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse's responsibility to ensure their practice remains up to date and reflects the latest evidence
Useful resources
- Resuscitation Council (UK) (2013) Lifesaver. www.resus.org.uk/apps/lifesaver
- Resuscitation Council (UK) (2015) iResus. www.resus.org.uk/apps/iresus
References
British Heart Foundation (2010) HeartStart Training – Choking. www.youtube.com/watch?v=IGCBcx8yKg4 (Last accessed: 4 July 2017.)
Fingerhut LA, Cox CS, Warner M (1998) International comparative analysis of injury mortality. Findings from the ICE on injury statistics. International Collaborative Effort on Injury Statistics. Advance Data. 303, 1-20. MEDLINE
Perkins GD, Handley AJ, Koster RW et al (2015) European Resuscitation Council guidelines for resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 95, 81-99. CROSSREF
Rogers S (2011) Mortality statistics: Every Cause of Death in England and Wales, Visualised. www.theguardian.com/news/datablog/2011/oct/28/mortality-statistics-causes-death-england-wales-2010 (Last accessed: 7 June 2017.)
Ruben H, Macnaughton FI (1978) The treatment of food-choking. The Practitioner. 221, 1325, 725-729. MEDLINE
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