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Medico-Legal Update

Uncommon choking: A case report

Author(s): Mohan N. Pawar, D.T. Patil, Hemant V. Godbole

Vol. 8, No. 2 (2008-07 - 2008-12)

Mohan N. Pawar٭, D.T. Patil٭٭, Hemant V. Godbole٭٭٭

٭Lecturer – Department of Forensic Medicine and Toxicology, Krishna Institute of Medical Sciences University, Karad, Dist. Satara, Maharashtra 415 110,
٭٭Professor – Department of Forensic Medicine and Toxicology, Krishna Institute of Medical Sciences University, Karad, Dist. Satara, Maharashtra 415 110,
٭٭٭Professor and Hod, Department of Forensic Medicine and Toxicology, RCSM, Government Medical College, Kolhapur, Maharashtra

Abstract

Death from choking is the fourth most common cause of unintentional-injury mortality. A little data is published on causes or locations of these episodes. These deaths typically are peaked at the extremes of ages, with young children and the elderly having the greatest rate of fatal choking. Though accidental cases of choking are noted, some of them are very rare which are caused by some unusual foreign bodies and in unusual way.

In this case report, a 16-year male was brought dead after accidentally engulfing the foreign body, when he was making fun. On postmortem examination a lemon was found impacted at the hypopharynx level. The cause of death issued was ‘Asphyxia due to choking’. The details of this case report are described in this paper.

Keywords: Choking, Foreign body, Asphyxia

Case history

A 16year male was brought dead with the history of accidental engulfing a lemon, when he was making fun by throwing it up and then taking in mouth. He did it for two times but third time it turned Fatal. The Postmortem examination was conducted on the same day. On Postmortem examination external examination revealed an average built teenager wearing T-shirt, full pant and undergarments. All cloths were dry and intact. Whitish froth was oozing through nostril. Nails were cyanosed. Rigor mortis was seen in neck muscles and partly in upper limbs. Postmortem Lividity was present over back and buttock except over pressure points and was not fixed. No injury was noted over the body.

On internal examination all organs were congested. Petechial haemorrhages were seen on heart surface (Fig. 1). Trachea, bronchi were full of whitish froth. Foreign body was seen impacted in hypopharynx, just behind the tonsils. It was lemon seen impacted in oropharynx, just behind the tonsils (Fig. 2). Lemon was pressing epiglottis and blocking the airway. It was firmly adhered to adjacent lumen.

Petechial haemorrhages were also seen on epiglottis and mucosal surface of trachea. Stomach contained about 200 ml semi digested food material without any abnormal smell still the viscera was preserved. The final cause of death was issued as “Asphyxia due to choking”.

Fig. 1: Petechial haemorrhages on heart surface.

Fig. 2: Impacted lemon behind the tonsils

Discussion

Airway obstruction can be anatomical or mechanical origin. Anatomical obstruction occurs due to anatomical structures such as tongue, swollen tissues of mouth and throat or results from injury to neck. Mechanical obstruction occurs due to foreign body1. Physical findings of wheeze, rhonchi, stridor, or retractions were associated significantly with a diagnosis of an unwitnessed foreign body2. Death due to choking is defined as unintentional ingestion or inhalation of food or other objects resulting in the obstruction of respiration3. In natural deaths due to choking there is obstruction of the airway by the inflamed epiglottis and adjacent soft tissue and are of anatomical origin as said above. But choking can also be homicidal or accidental4.

In 1973 the National Council reported nearly 2,500 such accidental fatalities a year; this ranks sixth in the United States among the leading causes of accidental deaths- far ahead of aircraft accidents, firearms, lightening and snakebite5. The most common specified food objects that victims choked on were meat products6. An aspirated Fis-Fis (Alfalfa, Lucerne) seed accounted for more than one-third of all foreign bodies7. In both groups, males and females were distributed equally and the most common ingested object was a coin2. A retrospective review of all the charts of children under 16 years old who underwent bronchoscopy shows, nuts and seeds are particularly dangerous8. Food material was the most commonly aspirated foreign body than the nuts9.

In this case it was the fun making moment of choking. There are various moments noted in the literature where the victims were either eating (11%), playing (83%) or studying (4%) or cleaning ears (2%)10. The majority of the choking episodes reported were occurred at home (45%), followed by supervised facilities (26%), restaurants (14%), hospitals (3%), the street (3%), hotels (2%), schools (2%), other (3%), and unknown locations (2%).6 Some of the common risk factors are old age, poor dentition, and alcohol consumption. Other risk factors included chronic disease, sedation, and eating risky foods11. In addition to this some of the other common causes of choking reported by American Red Cross are trying to swallow large pieces of poorly chewed food, eating while talking excitedly or laughing, or eating too fast. Walking, playing, or running with food or object in the mouth1. Many Indian authors reported that even a small object such as piece of coconut, gram-seed or monkey-nut partially blocking the air passage might cause death due to laryngeal spasm. Other foreign bodies noted are potato skin, fruit-stone, corn, button, coin, cork, rag, India-rubber teat, live fish, roundworm, mud, leaves12. Sonea Qureshi and Richard Mink noted that the most frequently aspirated objects are organic food items such as peanuts, popcorn, hot dogs, or vegetable matter. Nonfood objects include balloons, coins, pen tops, and pins13.

Gyan C.A. reported one case where a young male died during an attempt of swallowing a pool ball14. Tedeschi also reported four cases of accidental asphyxiation by food5.

Conclusions

Knowledge of the fact that semisolid foods are a high-risk factor in elderly individuals should be distributed in public and private healthcare systems, and awareness could be a first step in reducing the incidence of food/foreign body asphyxia. The degree of airway compromise and the severity of symptoms depend on the location and nature of the aspirated object. Items lodged in the oral cavity, hypopharynx, or larynx can produce airway obstruction leading to hypoxia, respiratory failure, or even cardiac arrest13. History from the investigating officer, relatives or other is always helpful. En-mass dissection is always superior.

From legal standpoint, the importance of establishing an exact diagnosis is obvious: whenever death is attributed to heart disease, the beneficiary of the estate is denied the double-indemnity insurance benefits that are allotted when death can be proved to have occurred as the result of accidental inhalation of food.

Acknoledgement

Authors are thankful to Dean of GMC, Nanded and Dr. N. P. Zanjad for kind support and help.

References

  1. American Red Cross. First Aid – Responding to Emergencies,1991; 84-93.
  2. Louie JP, Alpern ER, Windreich RM “Witnessed and unwitnessed esophageal foreign bodies in children.” Pediatr Emerg Care. 2005 Sep;21(9):582-5.
  3. Berzlanovich AM, Fazeny-Dörner B, Waldhoer T, Fasching P, Keil W. “Foreign body asphyxia: a preventable cause of death in the elderly.” Am J Prev Med. 2005 Jan;28(1):65-9.
  4. Vincent J. Dimaio, Dominick Dimaio. Forensic Pathology- Second edition 2001, 235-40.
  5. Tedeschi C. G.; William G. Eckert; Tedeschi L. G Forensic Medicine- a study in trauma and environment hazards, Edition 1977, vol. III, 1614-16.
  6. Dolkas L, Stanley C, Smith AM, Vilke GM. “Deaths associated with choking in San Diego county.” J Forensic Sci. 2007 Jan;52(1):176-9.
  7. Siddiqui MA, Banjar AH, Al-Najjar SM, Al-Fattani MM, Aly MF. Saudi Med J. “Frequency of tracheobronchial foreign bodies in children and adolescents.” 2000 Apr;21(4):368- 71.
  8. Shlizerman L, Ashkenazi D, Mazzawi S, Rakover Y. Harefuah. “Foreign body aspiration in children: ten-years experience at the Ha’Emek Medical Center.” 2006 Aug;145(8):569-71, 631.
  9. Goren S, Gurkan F, Tirasci Y, Kaya Z, Acar K. “Foreign body asphyxiation in children.” Indian Pediatr. 2005 Nov;42(11):1131-3.
  10. Gregori D, Morra B, Snidero S, Scarinzi C, Passali GC, Rinaldi Ceroni A, Corradetti R, Passali D. “Foreign bodies in the upper airways: the experience of two Italian hospitals.” Prev Med Hyg. 2007 Mar;48(1):24-6.
  11. Berzlanovich AM, Muhm M, Sim E, Bauer G “Foreign body asphyxiation—an autopsy study.” Am J Med. 1999 Oct;107(4):351-5.
  12. Modi’s Medical Jurisprudence & Toxicology, Edited by B V Subrahmanyam, 22nd Edition 1999, 273-4.
  13. Sonea Qureshi, MD and Richard Mink, MD “Aspiration of Fruit Gel Snacks” Feb 21, 2002, Harbor-UCLA Medical Center, Division of Pediatric Critical Care, Department of Pediatrics, 1000 W Carson St, Box 491, Torrance, CA 90509.
  14. Gyan C. A. Fernando “A Case of Fatal Suffocation During an attempt to Swallow a Pool Ball” Med. Sci. Law. (1989) Vol. 29. No.4, 308-10.

Address For Correspondence:
Dr. Mohan N. Pawar

pawarmnp (at) yahoo.co.in

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