is risky in these cases and may further lodge the foreign body. As a last resort, rescuers may consider performing cricothyroidotomy or transtracheal jet ventilation. This approach will only work if the surgical airway is placed below the foreign body. There are anecdotal reports of using high‐pressure jet ventilation to eject entrapped foreign bodies. However, there are no organized reports of choking management using cricothyroidotomy or jet ventilation.
For patients with partial airway obstructions, there are additional management options. The patient should be encouraged to cough and expel the object. High‐flow supplemental oxygen may be appropriate, although the sensation of the mask may make the patient feel uncomfortable, aggravating the situation. If the patient is able to adequately move air, it may be acceptable, and even preferable, to carefully transport the patient to the hospital for definitive care. In these cases, close monitoring of vital signs, oxygen saturation, respiratory effort, and level of consciousness are essential.
Monitoring end‐tidal carbon dioxide may also help to reveal early clinical deterioration, though research data on this are lacking. EMS personnel should provide advanced notification to the receiving facility so that the emergency department can prepare its equipment and summon appropriate personnel. Because this is an airway emergency, it typically makes the most sense to go to the nearest hospital. At the receiving hospital, the patient may require urgent sedation, direct or video laryngoscopy, or surgical airway intervention by an emergency physician, otolaryngologist, anesthesiologist, or surgeon. Many emergency departments have a “difficult airway” algorithm that involves summoning various specialists to provide assistance in these emergency airway situations.
Many postchoking victims refuse EMS care and/or transport. In general, however, it is recommended that patients who have their choking resolved before EMS arrival, or by EMS clinicians, be transported to the hospital for further evaluation to ensure that no complications have occurred [10, 13, 15]. This recommendation is based primarily on case reports of laryngospasm, pulmonary edema, anoxic brain injury, and retained foreign body occurring after choking episodes. In addition, there are case reports of damaged internal organs following abdominal and chest thrusts [23]. A patient who persists in refusing transport should be made aware of these possible risks.
As a final consideration, an anaphylactic reaction may masquerade as an upper airway obstruction, especially if the patient has recently eaten nuts [24]. If the history and presentation are suggestive of this situation, EMS clinicians should consider therapy with epinephrine and antihistamines.
Medical oversight considerations
Deterioration after complete airway obstruction occurs so rapidly that direct medical oversight by phone or radio likely provides minimal value. In cases of partial obstruction, direct medical oversight may provide useful guidance regarding management and receiving hospital options. The most important consideration is to educate EMS personnel to recognize signs and symptoms of partial and complete obstruction. As bystander intervention is essential in treating choking, EMS community outreach and education efforts are equally important. Prevention through activity with regulating authorities can lead to altering or relabeling objects or foods known to be significant choking risks [5, 6, 8, 9].
EMS physician presence at the scene may potentially play a role in select complicated choking cases. Patients with partial airway obstructions may prove to be difficult to manage, requiring a fine balance between supportive care and skilled airway intervention. An on‐scene EMS physician may facilitate selection of optimal treatment strategies. In the event of complete airway obstruction unresolved by basic techniques, an on‐scene EMS physician may be best qualified to perform advanced airway interventions, such as direct or video laryngoscopy and foreign body removal, rapid sequence intubation, or cricothyroidotomy. In all cases, the EMS physician’s value will be greatest if he or she is present at the earliest stages of the event—before complete airway obstruction or anoxic injury.
Controversies
The most important controversies in choking management are the use of back blows and chest thrusts. The Heimlich Institute opposes both of these techniques. The American Heart Association (AHA) recommends these interventions if the Heimlich maneuver fails, and the American Red Cross (ARC) also advocates for both [10, 11, 25]. The AHA and the ARC recommend chest thrusts instead of the Heimlich maneuver for unconscious, pregnant, and obese patients and for children less than 1 year of age.
Critics note that back blows can cause the object to lodge deeper and waste valuable time better spent performing the Heimlich maneuver. In a recent study, the Heimlich maneuver was 86.5% effective at removing an obstruction [13]. Back blows may prove effective in children less than 5 years of age [17]. Chest thrusts are associated with significantly higher morbidity and mortality than the Heimlich maneuver and should probably be reserved for the most serious choking victims [26]. Some of these controversies may be answered as the MOCHI study is getting underway in Japan and scheduled to conclude in 2023 [27].
Summary
Medical directors can be most successful by being active and providing community education. ACLS‐ and Pediatric Advanced Life Support–trained public and EMS clinicians have improved choking survival rates beyond 95% [10, 11]. Expeditious recognition and treatment of choking are essential and should ideally be accomplished by bystanders. EMS personnel arriving on the scene should be prepared to manage a patient in extremis. Patients with partial airway obstructions may tolerate supportive care and rapid transport to the hospital. All choking victims should receive transport to the hospital for evaluation. An observational cohort trial underway in Japan, MOCHI, may provide answers to many of the controversies surrounding foreign body airway obstructions.
References
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5 5 Committee on Injury, Violence, and Poison Prevention, American Academy of Pediatrics. Policy statement– prevention of choking among children. Pediatrics. 2010; 125:601–7.
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