Choking is basic first-aid, but we don’t deal with it much in the ED. Remember the basics – (1) if they can talk, leave them alone, (2) use the Heimlich or back slap to clear an obstruction.
Choking is about assessing the airway. (1) Can they talk? (2) Are they in distress? (3) Is the patient drooling? (4) Is there stridor, wheezing?
Our patient was unable to talk. He was not in distress, but he was drooling a little, and he was sitting forward . tripod-ing. There was no stridor or wheezing. His sat was in the high 80s. What do we do next?
The first step is the simplest. Look in the mouth. Very often, you will see the food in the mouth – it may be embedded (such as a bone in the tonsils) or way back in the upper airway. Grab it with your fingers or a long forceps.
When we looked in the patient’s mouth. We pulled out a piece of chicken. The patient was still unable to talk. He was still drooling. The sat is in the low 90s. What do we do next?
The second step is to look at the airway. There are many different ways to do this. The simplest way is to look in the airway with direct laryngoscopy, i.e. a Mac blade that you would use for intubation. Most EDs have video laryngoscopy equipment as an alternative option. The advantage of the Mac blade is that you can grab the food with a long forceps right then and there. With the video laryngoscopy, it’s not as easy to remove the foreign body.
We scoped the patient. There was no additional foreign body, but there was a lot of secretions. The next step is to admit the patient for observation. The patient likely aspirated his secretions, and there is a small chance that the patient aspirated a food particle. A CXR may be diagnostic (remember the findings we were taught in peds?). Most patients do not require bronchoscopy – food particles tend to be big and they don’t usually go into the trachea / bronchi. Patients do not necessarily need to be admitted depending on their symptoms, findings, and risk factors (I generally admit patients with developmental delay).
In about half an hour or so, the patient cleared his secretions and his sat returned to normal. He was admitted for observation and he did fine. We spoke to his caretaker about cutting up the patient’s food carefully.