When a Child Chokes
Most people think of the alphabet song, typically sung to the tune of “Twinkle, twinkle, little star” when they hear the “ABCs.” Me? Not so much. I think of Airway, Breathing, and Circulation. This is drilled into every young emergency medicine trainee’s mind over and over, and in succession. You can’t have B(reathing) if you don’t have an A(irway), etc. It sticks with you, trust me.
So that’s where we always start in our patient assessment.
“Does this person have an airway?”
Sort of an unusual thing to say, right-? Well, maybe not. Stay with me here: what is meant by this is whether or not the child has a patent (or open) airway. If so, it’s appropriate to proceed onto the breathing assessment, and if not, the clinical work entails establishing an airway. By whatever means necessary, and sometimes that entails inserting a breathing tube into the airway. Thankfully, that’s not often.
This preamble is meant as a setup for a practical discussion about choking. I see children fairly regularly who come in with the report of having “choked’ prior to their arrival. It’s always a little difficult to know exactly what to make of this chief complaint and whether or not the child was truly choking, and if he wasn’t, whether or not some aspiration/inhalational event occurred and what to do about that.
Let’s start with the Captain Obvious stuff. Someone who is choking has an obstructed airway and cannot adequately get air from the outside of their body to the inside. We’ve all been taught about the signs of choking:
Partial Airway Obstruction
If any sound or cough or gasp is able to be heard, then the airway is NOT totally obstructed. As a general rule if someone is coughing it’s best not to intervene with a technique such as the Heimlich maneuver and simply let the child cough and recover on their own (but feel free to position them upright and leaning forward to assist with removal of whatever is stuck), but if there are any of the signs above present, then the Heimlich maneuver can be life saving. Learn it, know it, so if necessary you can use it. I’ve shared an infographic below. OK, got it.
But what about that group of kids who get brought in to acute care AFTER a choking-type event?
Many times these are instances where there was a temporary partial airway obstruction that has been resolved, so is there any particular reason to be concerned? That depends, so here’s how I approach the medical decision making:
By the time this group of patients arrives in acute care they clearly have an established airway, so the first thing I do is assess their breathing:
1. Is it fast?
3. What’s their oxygen level?
4. Do the lungs sound clear?
Answering all of these questions helps to determine whether or not there has been an aspiration event after the “choking” episode. What this means is that sometimes whatever caused the airway obstruction, whether total or partial, gets lodged further down the airway, and can cause respiratory distress and even ultimately pneumonia. Oxygen exchange gets impaired and thus not enough goes to the tissues, triggering an increase in respiratory rate and work of breathing in an attempt to make up for it. Kids who have this condition do not look well, and it sometimes takes several hours after the event to demonstrate this degree of symptoms. Antibiotics, supplemental oxygen and respiratory support and hospitalization can be required to support a child through this type of aspiration pneumonia.
I’ve just described the sickest group.
The majority of kids who are able to clear an obstruction in their airway on their own will cough, sputter and even throw up, but will ultimately be just fine without need for further intervention. Of course it’s reasonable to undergo some evaluation and observation for a bit just to convince everyone that things are ok, and this time spent can be important. It can be used to make sure the child can breathe effectively and comfortably and hydrate without difficulty, without going into respiratory distress. Often, even if not medically necessary, the reassurance of witnessing this helps everyone sleep better at night, and that is priceless therapy. So if your child has a choking type of event that works itself out, it makes sense to have a medical evaluation but not necessarily something like a chest xray. And if no xray is done, that doesn’t mean the visit was a waste of time.
Of course, the best way to manage any choking event is to prevent it from happening in the first place. We all know about cutting up grapes, hot dogs, pieces of meat, etc in very small pieces prior to allowing children to eat those foods, but it’s also important to remember to pick up small toy pieces or other small parts like tops of pens, coins, batteries and other similar items off of the floor or wherever younger kids have easy access so that they don’t put them in their mouths. Also, discourage kids from taking bites of food while laughing and being overly silly as this increases the chances that they could accidentally inhale part of that bite into their lungs.
And finally, know how to do the Heimlich.
The technique is different for kids, so refresh your knowledge if necessary. We all have a lot of birthday parties, holiday meals, and restaurant outings ahead of us, so best to be prepared to step in to save the day if need be. I know you can do it!