From the Department of Medicine, University of South Carolina School of Medicine, Columbia, SC.
Reprint requests to Shawn Chillag, MD, Department of Medicine, University of South Carolina School of Medicine, Two Medical Park, Suite 502, Columbia, SC 29203. Email: Shawn.Chillag@uscmed.sc.edu
Accepted August 24, 2009.
None of the authors have any financial disclosures to declare or conflicts of interest to report.
The very young and the very old are vulnerable to choking, and there are over 4000 choking-related deaths annually in the United States. Complications from the Heimlich maneuver (HM), as reported in infrequent case reports, predominantly relate to the elderly. It is doubtful that the denominator, numerator, appropriateness, expertise, and problems of maneuvers applied to choking victims will ever be known. This case report and literature review suggests that the treatment for acute elderly choking victims should be applied carefully and that esophageal food impaction, which should be rapidly distinguishable from choking, can have serious complications with application of the HM.
* There are over 4000 choking deaths in the United States annually.
* Laceration or rupture of the stomach is the most frequently reported life-threatening complication of the Heimlich maneuver (HM).
* The very young and the very old are the most likely to choke and the most vulnerable to serious complications.
* The collapse of a choking victim after application of the HM should prompt rapid evaluation for gastric, aortic, and cardiac injury.
* A person in distress while eating who can talk and breathe does not have a critically obstructed airway.
The Heimlich maneuver was first publicized in 1975 by Henry Heimlich.1 Since that time, his thoughtful, scientific, vigorous promotion of this technique may have saved the lives of many choking victims without serious side effects. Rare complications have been reported, at times, from an improperly performed Heimlich maneuver (HM). We report the first case of an acute vertebral fracture and collapse associated with application of an HM. We review all the significant complications reported in the English literature (found through a PubMed search). Some observations on the use of the HM, its benefits, and its dangers are offered.
An 80-year-old woman developed worsening low back pain with muscle spasm. Two days earlier, a HM had been performed on her by an untrained person after a choking episode at a family dinner. The next morning, she developed incapacitating pain and spasms in her mid and lower back aggravated by movement. She had past osteoporotic thoracic vertebral fractures, was a smoker, and had had dysphagia. Examination revealed no focal neurologic deficit with percussion tenderness about the lumbar vertebrae. Thoracic and lumbar spine magnetic resonance imaging (MRI) showed multiple thoracic vertebral compression fractures with an acute T5 collapse. Acute compression deformities were present at L1–L2 levels with marrow edema. She was treated with morphine, diazepam, and calcitonin. Incapacitating pain persisted and was unrelieved by narcotics. She underwent kyphoplasty for the L1–L2 fractures with rapid improvement in her pain. A swallowing study revealed significant aspiration with an otherwise negative evaluation. A gastrostomy tube was placed. She was transferred to a rehabilitation hospital.
After Henry Heimlich described his maneuver, there were public education programs, the posting of instructional cards, and much discussion of the best techniques for emergency treatment of the café coronary. The country of Uganda even issued a postage stamp in 1990 showing Mickey Mouse performing the HM on Donald Duck.2 Early on, Dr. Heimlich and others studied animals and cadavers to describe the pressures generated. It is estimated that there are 3000 to 4000 choking deaths annually in the US with 4,093 reported in 2004.3,4 The National Research Council reported in 1976 on 500 lives already saved by the HM.5 American Heart Association data found two serious complications; retinal detachment and esophageal laceration occurring with 168 applications of the HM.5 Other than this generally discussed series of cases, all the information about HM complications comes from case reports.
Most choking emergencies are at the extremes of age. Calls about choking to emergency medicine services make up 3 to 4% of calls for children less than 5 years old.6 Choking accounted for 0.27% of all adult emergency calls in San Diego County over an 18-month period. The mean age of the 513 callers was 65 years. The mean age of the 17 (3.3%) who died was 76 years. The HM was used in 16.4% of cases and supine abdominal thrust in 2.7%; 86.5% improved with use of the HM.6 Over a 10-year period in San Diego County, there were 133 choking deaths with a median age of 73.7 Over half (53%) had neurologic or anatomic problems related to swallowing. Meat was the most common agent in this and in any large study of adult choking. Austrian and Australian studies of fatal choking echo the US study of the victims; victims are often old, suffer from central neurologic deficits, are institutionalized, use psychotropic medications, and/or consume alcohol and risky foods.8,9
The PubMed search revealed 125 citations for Heimlich maneuver. There were 41 cases of significant injury with sufficient documentation to be considered (Table). There were 27 cases of injury in the abdomen or diaphragm, and there were 14 cases of injury in the thorax. There is a report of an internal carotid dissection and one of a retinal detachment related to HM.5,10 Heimlich described rib fractures and minor problems of abdominal pain, vomiting, and pharyngeal abrasions. One case of vomiting in a child led to aspiration with anoxic brain damage and a persistent vegetative state.11
Table. Heimlich mane...Image Tools
Of the 27 abdominal injuries, 13 were severe lacerations or ruptures of the stomach, all on the lesser curvature ranging from 2 cm to 10 cm long.12–22 All were in adults from age 39 to 93 with 9 older than 60 years; one report gave no age. All but one, who died rapidly, underwent emergency surgery with 4 expiring and 8 doing well. In many of these reports it was difficult to ascertain if the HM was definitely indicated or performed correctly. An unknown category was used if it was not clear. In 8, the HM was definitely needed; in 5 it was unknown. It is not clear if the HM was performed properly in any of the 13. Seven of these had repeated efforts which may be appropriate, but some descriptions seemed excessively zealous. The lesser curvature is felt to be the injured site because it is less distensible with fewer mucosal folds.18
There was one jejunum rupture in a 22-year-old man who did well with surgery.23 An institutionalized case had several HMs done for choking that resulted in diaphragm rupture with gangrenous bowel in the chest. He expired despite surgery.15 An improperly performed and unnecessary HM resulted in a pancreatic transection in an 11-year-old boy who did well with surgery.24 A 3-year-old boy developed pancreatitis and a pseudocyst that caused no long-term problems.25 There was a laceration of the left lobe of the liver in an 88-year-old man requiring no surgery.26 A 51-year-old man died from asphyxiation after a needed HM was improperly used (force was applied below the umbilicus); autopsy disclosed laceration of the mesentery and intraperitoneal hemorrhage.27
There were 8 major aorta injuries with 6 deaths.28–34 One survivor had displacement of a prior stent endograft and was doing well with surgery.33 The other survivor had surgery for thrombosis of a 4.5 cm aneurysm with a leg amputation and permanent hemodialysis.30 One man had an incorrect application of the HM resulting in thrombosis in an abdominal aneurysm; he expired. One thrombosis of the aorta without aneurysm was treated with tissue plasminogen activator with a poor outcome. Another died from ruptured aortic dissection without an aneurysm. The HM definitely seemed needed in 6 of the 8. Aneurysms were present in 5, and an atherosclerotic aorta was present in all. The age range was from 62 to 84 years; 6 of the 7 were men.
Among the 14 thorax injuries, 3 involved the esophagus, 4 the mediastinum, 5 the rib cage, and 2 the aortic valve. The three esophageal injuries were perforations requiring surgery; each had a full recovery.35–37 All had esophageal impaction of food and could speak; the HM was not indicated. All were adults. There were 4 cases with pneumomediastinum, one also with pneumopericardium, and another with rib fractures as well.38–41 In none of these was the HM indicated. A 56-year-old man had herniation of a bulla into the mediastinum requiring surgery.42 Rib fractures were the sequelae of the HM in 3 cases, and in 2 of these cases, the HM was both unnecessary and improperly performed.42,43 A 74-year-old woman developed multiple, bilateral costochondral fractures after an HM.44 A prosthetic aortic valve cusp ruptured after a HM, and the patient did well with surgery.45 An 86-year-old man refused surgery for a native aortic valve cusp rupture and died several days later.46
Choking is a bimodal problem of the young and the elderly. Choking is variously the fourth to sixth cause of injury-related death in the elderly. Deaths from choking will surely increase as America ages. When the HM is used in standing children, it is recommended that the force used be less than would elevate the feet from the floor. This seems reasonable for a frail elderly person.
The significant loss of height that occurs with aging is axial; the lower rib to pelvis distance may decrease significantly with aging, perhaps making the xiphoid to umbilicus target for the usual HM not always achievable. Standard recommendations for choking advise back blows and abdominal thrusts (HM) with cautious use in the infant.47 The details and cautions of recommended choking first aid seem less well known by the public than the HM. In the recent movie Choke (2008), the main character repeatedly feigns choking in restaurants to gain a bond with rescuers who perform the HM (incorrectly).
The information from this review indicates that choking first aid is often performed when it is not required, and it is often performed incorrectly. Particular care seems indicated in the frail elderly with altered anatomy, vascular disease, fragile bones, and frequent esophageal swallowing problems. First aid for choking is a mixture of science and expert opinion without enough evidence. A focused public education effort in a metropolitan locale with measurement of outcomes might help with expanding the evidence. The magnitude of the problem and the growth of the frail elderly would seem to warrant the investment in an area such as San Diego County.
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