‘I choked on a carrot this afternoon and all I could think was ‘I bet a donut wouldn’t have done this to me.’’

Quote author unknown

Whilst choking is a deadly subject, we saw this quote and it made us laugh, hence why we started this month’s blog with this quote. Does it matter whether the choking obstruction is a carrot or a doughnut? Obviously, no it doesn’t.

Humans are 500 times more likely to choke than any other animal

What is Choking?

The dictionary definition of the word choke is:

  • (of a person or animal) have severe difficulty in breathing because of a constricted or obstructed throat or a lack of air.
  • fill (a space) so as to make movement difficult or impossible.

The word choke is classified in the Oxford English Dictionary as a verb.

What is the Airway?

An airway consists of 4 key components as follows:

  • Nose,
  • Mouth,
  • Trachea,
  • Lungs.

The nose and mouth are obviously the most visible part of the airway and are the air intake parts of the airway as well as the main entrance for foreign objects to get stuck in the trachea. The trachea is the major part of the airway that has the biggest role to play in whether a casualty chokes or otherwise. A fully developed adult trachea has an open diameter of just 14 to 15 millimetres, compared to just 5 millimetres in young babies. As the child develops, the size of the diameter of the trachea never exceeds the child’s age. So you can see from that statistic alone, even an adult can choke on quite small objects. The last part of the airway to discuss is obviously the lungs. The lungs are the organ of the body that deals with the gas exchange in the body, providing oxygen to the blood for the heart then to deliver around the body.

Why does choking happen?

The reason that humans are so much more likely to choke than other species of animal is because we talk. This may sound like a strange thing, but what it means is that our voice box is higher up in the body than in other animals, and this causes an issue as it brings our trachea (windpipe) and oesophagus (food pipe) closer together. Nature has tried to prevent choking with the ‘invention’ of the leaf shaped piece of cartilage called the epiglottis which is meant to close over the trachea as you swallow, meaning you cannot swallow and breathe and also objects can only enter the oesophagus. The epiglottis works when it receives a message from the brain telling it to close as the body is about to swallow.

So, in summary choking occurs because the brain gets distracted and then doesn’t have time to tell the epiglottis to close.

In 2016, 289 people died from choking in England, Scotland and Wales, up 17% from the previous year.

Office for National Statistics

What causes choking?

According to the American Academy of Pediatrics (AAP) there are 9 most common foods that children choke on. In the US the AAP reports that 1 child under 14 dies every 5 days from choking. The AAP is calling for the food industry to change the design and label of foods that pose a risk of choking. This would be a good idea and something that potentially the UK Government could look into in the future too in our opinion.

The 9 foods most at risk of causing choking according to the AAP are as follows:

1 – Hot Dogs (Sausages in general)

Hot dogs have been found by research to be the most common cause of choking, with 17% of deaths from choking because of a hot dog.

The problem with hot dogs/sausages is the shape and size of the sausage makes it a perfect plug in the trachea. The consistency of the hot dog also, ensures that the sausage plugs the airway and doesn’t allow any air to flow through into the lungs.

Paediatricians in the United States say that parents should be reminded to mince or thinly slice the hot dog before giving it to children. Other advice, like other foods on this list, is that they are recommended to be withheld from children until they turn 4.

2 – Chewing Gum/Boiled Sweets

Most boiled sweets or other hard sweets otherwise referred to as hard candy (particularly in the US) is formed by the manufacturer into a perfect circle shape which encourages it to get stuck in the airway.

Should a chid laugh, take a deep breath, get distracted or try to swallow the sweet whole, it can easily get lodged into the trachea. We mustn’t forget lollipops when we look at these issues as children have a bad habit of not holding onto the sticks and as they suck in, they can easily get the lollipop stuck in the trachea. A parent or first aider may be able to see the stick and consider it a good idea to try to remove the lollipop by pulling on the stick, however this is a big no-no as there are many complications that this can cause, including removing the stick but leaving the lolly in place and having wasted the time to help the child.

This type of hazard is the second biggest killer, and research shows it accounts for 10% of all choking deaths.

3 – Grapes

According to a United States survey, grapes are the 3rd biggest killer with 9% of child deaths of choking on a grape behind only hot dogs and hard-boiled sweets or hard candy as they call it.

Naturally as a grape grows, they are the perfect shape, size and consistency to get blocked in the child’s airway.

Simply cutting the grape without thinking about what you are doing is not enough, when preparing a grape you have to think about the direction of the grape you are cutting. We advise that the grape is cut from pole to pole rather than across the equator, providing the grape is not a round grape but rather an oblong. Should the grape be a round shape, it is best to cut this into quarters.

4 – Nuts

Nuts’ shape and size make them very dangerous for children and should therefore be avoided for young children.

Nuts are the 4th most common cause of child death from choking at 8%.

5 – Carrots

Carrots again, when traditionally sliced, form the perfect shape and size to plug the child’s airway, and therefore prevent air from flowing into the lungs and stop the lungs from fulfilling their normal working roles.

Simply cooking the carrots until they are of a mushy consistently or slicing them into batons rather than the traditional disc will reduce the choking risk of these orange vegetables of goodness.

6 – Apples

One of the issues with an apple is the skin, which can keep the apple in a size which will then fall into and block the casualty’s airway. Other issues with the apple is how it is prepared and then provided to the child.

It is a good idea to chop the fruit into small manageable pieces or cook to mushy throughout.

7 – Peanut Butter

Peanut butter has several issues when it comes to serving this to anyone firstly, and not choking related, it is important that peanut butter, just like nuts, can actually cause an allergic reaction and therefore you will need to ensure that the person you are serving this to is not allergic to the food.

When we look at peanut butter as a choking hazard it may seem strange that it is on the list as it is a smooth spread. The thing which makes peanut butter so dangerous for children and adults in terms of a choking risk is that a large dollop can coagulate in the mouth and make it difficult to swallow, and therefore when it goes down the back of the throat, it gets stuck in the trachea and prevents air from passing through to get to the lungs.

The safest way to eat peanut butter is thinly spread on a slice of bread or a cracker and with a drink, to help keep the mouth moist while consuming the snack.

8 – Marshmallows

A marshmallow is made of a mixture of sugar, air, water and gelatine, which therefore makes the item soft and easy to get lodged into the child’s throat. Simply, they should be avoided where children are concerned.

Parents should also consider what they are purchasing if and when they go out for a coffee with friends, especially as some coffee shops offer hot chocolate with the works, which usually includes mini marshmallows which are already starting to melt because of the temperature of the drink. This will lower the awareness of the choking hazard and in actuality this is a dangerous situation as they are starting to melt and subconsciously they are seen as being safe.

9 – Popcorn

The last on the 9 biggest causes of choking deaths is popcorn.

Popcorn seems to be the fun and exciting food stuff and often given to children as a treat. The issue comes when you realise that the size and shape of the popcorn makes it a really easy food to choke on.

Of course there are many more things that can cause choking, we have purely focused in this blog on the 9 most common choking death causes.

According to Injury Facts in 2017, choking is the 4th leading cause of unintentional injury death

How can you prevent choking?

Preventing choking in our opinion is much better than having to do first aid on a casualty who is choking. However, it is not guaranteed that choking will not occur even if you reduce the risk, but you have done all you can to minimise the risk and potentially saved a life by taking a few seconds to think.

Our first prevent choking advice would be to continue to follow all the good ‘table manners’ rules that we have been using as a society over many years. By this we mean things like:

  • Sit when eating,
  • Chew food carefully,
  • Don’t ram too much in your mouth,
  • Don’t talk as you eat,
  • Supervise children when they are eating,
  • Try not to do too many things at the same time as eating.

Just to pick up on one of those points above, we have heard of some people having chewing rituals which include chewing your food a certain number of times before swallowing; the number changes each time we hear it but some people swear by it.

Some very simple advice that we can provide is to remember to cut food, the direction that you cut food will be important so as it is not the same shape and size as the trachea itself. As we referred to earlier when discussing grapes, it is important that they are cut in vertical direction from pole to pole and not horizontally, so that if the grape gets stuck in the trachea, there will be a gap between the obstruction and the wall of the trachea allowing air to flow through the trachea.

When we are talking about cutting foods, it is not just the grape that we need to think about. When you are preparing food, it is important to consider the shape of the food, should the food be a circular shape, it is better to slice the food object into an oblong shape, allowing it to have air flow around it in the trachea should it get stuck.

Other advice we can give is to ensure that you read the instruction manual and heed any warnings that are written on the label. A lot of labels will state ‘Choking hazard – Not Suitable for children under 3 years’ in this situation you should heed this warning as it has been deemed the perfect size to cause a choking hazard to children.

We have one other piece of advice which we feel can save many lives. This advice would be to avoid feeding children while there are in a moving car. We appreciate that some parents do this to pacify the child allowing them to focus on driving the vehicle. The problem with this practice is that the force involved in hard braking will lurch the child’s body forward, and once the pressure on the brake is released the reflex action in the body will force the food in the child’s mouth to fly backwards into the throat of the child, more likely ending up in the child’s trachea. This will obviously result in the child choking. Choking is a silent killer, and as the child in the back seat will be pacified and quiet, it is not unheard of for the parent to think the child is simply asleep.

Sadly, over recent years, children have died in their car seats due to choking on something that they have been given to eat while in the car. We hope that by including this piece of advice we can prevent more children from dying in this manner.

Along with not providing children with food whilst they are in a moving vehicle, adults should also consider what toys they are providing the children to entertain them whilst the vehicle Is motion, as any small parts that can become detached can also cause choking.

To finalise our advice on children in cars, we would like you to consider:

 How long will it take you to:

  1. Safely pull the car off the road.
  2. Remove your seatbelt.
  3. Exit the car.
  4. Open the car door next to the choking child.
  5. Release the car straps of the child.
  6. Follow the treatment steps below?

Choking is a silent killer,

From the second you start to choke to the second you end up on the floor is as little as 30 – 45 seconds.

Signs and Symptoms of Choking

Choking usually occurs when the casualty is eating or drinking, which would make it fairly easy to distinguish as the event that is happening. If your casualty is old enough to answer questions and understand what is being asked of them you should ask ‘Are you choking?’

There are 2 types of choking. These are Mild and Severe choking.

Mild Choking

If the casualty’s choking is mild, the casualty will be able to cough and answer ‘yes’ to your questions.

Severe Choking
  • Attempts to cough not working,
  • Unable to talk or cry – may ‘nod’ in response to your question,
  • Breathing sounds wheezy or absent,
  • Distressed look on the face,
  • Skin may flush but then goes pale/blue,
  • Rapid reduction in consciousness as oxygen runs out.

Injury Facts (2017) found 85% of all choking deaths are caused by food obstructions

Treatment of Choking

Treatment for a baby Under 1

The baby who is choking may attempt to cough. If the choking is only mild, the cough should clear the obstruction, this may then allow the baby to cry and they should now be able to breathe effectively.

Should the cough not work the following steps should be followed:

Back Blows:

  • Shout for help! – Do not leave the baby yet,
  • Sit or kneel the baby over your lap, face down with their head lowest, ensuring that you are supporting the child’s head,
  • Give up to sharp blows between the shoulder blades with the heel of your hand. Check between each one to see if the child has had the obstruction removed.

Please note that the object is to remove the obstruction with each blow rather than to give all 5.

Chest Thrusts:

Should the obstruction not have been cleared, follow the following steps:

  • Turn the baby uppermost, laying them on your arm,
  • Support the head and lower it below the level of the chest,
  • Use 2 fingers to give up to chest thrusts.

Chest thrusts are similar to chest compressions but are sharper in nature and delivered at a slower rate

As with Back Blows the object is to remove the obstruction with each thrust rather than to give all 5.

NEVER perform abdominal thrusts on a baby!

If the obstruction has not been dislodged and the casualty is still choking, ensure you follow these instructions:

  • Keep repeating Back Blows followed by Chest Thrusts,
  • Shout for help!
  • Ask someone to call 999/112 for emergency help, do not do this yourself whilst the child is still conscious,
  • Start CPR, if the baby becomes unconscious,

St John Ambulance have created an easy to remember video for baby CPR view it here.

Treatment for a casualty Over 1

The first action that you should do is encourage the casualty to cough. You could use the question ‘can you cough?’

If the casualty is only choking mildly, the cough should clear the obstruction. This will then allow the casualty to speak to you. Letting you know that they are breathing effectively.

Should the cough not work the following steps should be followed:

Back Blows:

  • Shout for help! – Do not leave the casualty yet,
  • Get the casualty to place their hands on their knees,
  • Give up to sharp blows between the shoulder blades with the heel of your hand. Check between each one to see if the child has had the obstruction removed.

Please note that the object is to remove the obstruction with each blow rather than to give all 5.

Abdominal Thrusts:

Should the obstruction not have cleared, follow the following steps:

  • Stand the casualty up,
  • Ask them to place their hands on their belly button,
  • Stand behind casualty,
  • Use their arms to guide your arms around into their abdominal area,
  • Make a fist with one hand and place it above the casualty’s hands,
  • Grasp this fist with your other hand,
  • Pull sharply and firmly inwards and upwards,
  • Do this up to times.

As with Back Blows the object is to remove the obstruction with each thrust rather than to give all 5.

If the obstruction has not been dislodged and the casualty is still choking, ensure you follow these instructions:

  • Keep repeating Back Blows followed by Abdominal Thrusts,
  • Shout for help!
  • Ask someone to call 999/112 for emergency help, do not do this yourself whilst the casualty is still conscious,
  • Start CPR, if the casualty becomes unconscious.

The British Heart Foundation has created a funny, easy to follow CPR video; you can view it here.

Why not watch this St John Ambulance video, – The Chokeables to remind you how to save someone’s life who is choking.

What should I do after successful treatment?

Should you have successfully treated a choking casualty there are things that you should do.

Firstly, should you have removed the obstruction with rescue breaths as part of CPR, you will have blown the obstruction down into the casualty’s right lung, as they are now breathing, it would be a good idea to use the recovery position, placing them onto their right-hand side.

There are occasions when you would need to make sure your casualty seeks medical attention these are:

  • The casualty has received abdominal thrusts.
  • The casualty has difficulty breathing.
  • They have a persistent cough.
  • The casualty feels that they have an object stuck in their throat.

Throughout this article we have explored choking risks and the treatment, whilst information is important and can save lives, should this have got you thinking, could I save a life doing this? why not book a First Aid course with us, where you will have the opportunity to practise the back blows, chest thrusts and abdominal thrusts on our training mannequins.

We look forward to seeing you on one of our courses.

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