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Bandini A, Gandhi P, Sutton D, Steele CM. Bolus Texture Testing as a Clinical Method for Evaluating Food Oral Processing and Choking Risk: A Pilot Study. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:2806-2816. [PMID: 36251878 PMCID: PMC9911109 DOI: 10.1044/2022_ajslp-22-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/04/2022] [Accepted: 06/21/2022] [Indexed: 05/03/2023]
Abstract
PURPOSE Choking on food is a leading cause of accidental death in several populations, including children, people with intellectual/developmental disability, and older adults in residential care facilities. One contributor to choking risk is incomplete oral processing and failure to convert food to a cohesive, nonsticky bolus with a maximum particle size that will not block the airway. Clinical tests of mastication do not evaluate properties of chewed food boluses. We characterized expectorated boluses, after oral processing, using methods developed by the International Dysphagia Diet Standardisation Initiative (IDDSI). METHOD Seventeen adults without dysphagia (seven women and 10 men), aged 23-55 years, chewed samples of a cracker, a raw baby carrot, and a circular, dome-shaped gummy candy. Chewing metrics were obtained up to the point when the person indicated that they were ready to swallow. The bolus was then either expectorated or swallowed; IDDSI tests were used to characterize the expectorated boluses. RESULTS Measures of chewing did not differ between spit and swallow conditions. Expectorated cracker and carrot boluses had maximum particle size consistent with IDDSI Level SB6 Soft & Bite-Sized foods or lower. The gummy candy samples remained at IDDSI Level RG7 Regular food consistency. CONCLUSIONS This study suggests that expectorated ready-to-swallow boluses are representative of boluses that are swallowed and that oral processing in adults without dysphagia typically results in boluses at IDDSI's Level SB6 or lower. IDDSI's testing methods provide a practical method for evaluating oral processing by characterizing expectorated ready-to-swallow boluses and may guide food texture recommendations for persons who have increased risk of choking.
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Affiliation(s)
- Andrea Bandini
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- The BioRobotics Institute, Suola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Danielle Sutton
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
| | - Catriona M. Steele
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
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Birkun A. Toward development of the standardized dispatcher algorithm for telephone assistance in choking. Acad Emerg Med 2022; 29:1401-1402. [PMID: 35881011 DOI: 10.1111/acem.14572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Alexei Birkun
- Department of General Surgery, Anaesthesiology, Resuscitation and Emergency Medicine, Medical Academy named after S.I. Georgievsky of V.I. Vernadsky Crimean Federal University, Simferopol, Russian Federation
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Katabami K, Kimura T, Hirata T, Tamakoshi A. Risk Factors of Mortality from Foreign Bodies in the Respiratory Tract: The Japan Collaborative Cohort Study. Intern Med 2022; 61:1353-1359. [PMID: 35491176 PMCID: PMC9152875 DOI: 10.2169/internalmedicine.8437-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective This study assessed the risk factors of mortality from foreign bodies in the respiratory tract using the Japan Collaborative Cohort Study for the Evaluation of Cancer Risk data. Methods Data of 110,585 participants 40-79 years old living in 45 areas in Japan were collected between 1988 and 2009. Mortality from foreign bodies in the respiratory tract was assessed in a multivariable-adjusted analysis using a Cox proportional hazard regression model. Results Among all participants, 202 deaths occurred from foreign bodies in the respiratory tract. In the multivariable-adjusted model, older age [50-59 (hazard ratio, 4.93; 95% confidence interval, 1.91-12.74), 60-69 (hazard ratio, 14.96, 6.01-37.25) and 70-79 (hazard ratio, 53.81; 95% confidence interval, 21.44-135.02) years old compared to 40-49 years old], male sex (hazard ratio, 2.34; 95% confidence interval, 1.54-3.54), a history of apoplexy (hazard ratio, 7.04; 95% confidence interval, 4.24-11.67) and the absence of a spouse (hazard ratio, 1.56; 95% confidence interval, 1.05-2.32) were associated with an increased risk of mortality from foreign bodies in the respiratory tract. Conclusions Older age, male sex, medical history of apoplexy and the absence of a spouse were potential risk factors of mortality from foreign bodies in the respiratory tract. Especially in elderly men, social connections, such as cohabitation or relationships, may be important for ensuring the early detection of asphyxia and preventing death due to foreign bodies in the respiratory tract.
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Affiliation(s)
- Kenichi Katabami
- Department of Public Health, Hokkaido University Graduate School of Medicine, Japan
| | - Takashi Kimura
- Department of Public Health, Hokkaido University Graduate School of Medicine, Japan
| | - Takumi Hirata
- Department of Public Health, Hokkaido University Graduate School of Medicine, Japan
| | - Akiko Tamakoshi
- Department of Public Health, Hokkaido University Graduate School of Medicine, Japan
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Hemsley B, Steel J, Sheppard JJ, Malandraki GA, Bryant L, Balandin S. Dying for a Meal: An Integrative Review of Characteristics of Choking Incidents and Recommendations to Prevent Fatal and Nonfatal Choking Across Populations. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1283-1297. [PMID: 31095917 DOI: 10.1044/2018_ajslp-18-0150] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose The purpose of this study was to conduct an integrative review of original research, across adult populations relating to fatal or nonfatal choking on food, to understand ways to respond to and prevent choking incidents. Method Four scientific databases (CINAHL, Medline, Web of Science, and EMBASE) were searched for original peer-reviewed research relating to fatal or nonfatal choking on foods. Data were extracted on study characteristics; factors leading up to, events at the time of, and actions taken after the choking incident; and impacts of choking incidents. An integrative review of the findings across studies identified several risk factors and recommendations to reduce the risk of choking. Results In total, 52 studies met the criteria for inclusion in this review, of which 31 were quantitative, 17 were qualitative, and 4 were of a mixed methods design. Studies reported the observations and narratives of bystanders or researchers, or else were large-scale autopsy studies, and included both the general public and people at risk of dysphagia. A range of food types were involved, and several actions were reported in response to food choking. Strategies to reduce the risk of choking were identified in the studies and are presented in 5 main categories. Conclusions Factors leading up to choking incidents extend well beyond the individual to the environment for mealtimes; the provision of appropriate mealtime assistance and oral care; and regular monitoring of general health, oral health, and medications. Bystanders' increased awareness and knowledge of how to respond to choking are vital. The results of this review could be used to inform service policy and training, for individuals at risk of choking, the people who support them, and the general public. Further research is needed to explore choking prevention and airway protection in individuals with dysphagia. Supplemental Material https://doi.org/10.23641/asha.8121131.
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Affiliation(s)
- Bronwyn Hemsley
- Graduate School of Health, The University of Technology, NSW, Sydney, Australia
| | - Joanne Steel
- Graduate School of Health, The University of Technology, NSW, Sydney, Australia
- The University of Newcastle, NSW, Australia
| | - Justine Joan Sheppard
- Department of Biobehavioral Sciences, Teacher's College, Columbia University, New York, NY
| | - Georgia A Malandraki
- Department of Speech, Language and Hearing Sciences, Purdue University, West Lafayette, IN
| | - Lucy Bryant
- Graduate School of Health, The University of Technology, NSW, Sydney, Australia
| | - Susan Balandin
- School of Health & Social Development, Deakin University, Melbourne, Victoria, Australia
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Luczak A. Effect of body position on relieve of foreign body from the airway. AIMS Public Health 2019; 6:154-159. [PMID: 31297401 PMCID: PMC6606524 DOI: 10.3934/publichealth.2019.2.154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/16/2019] [Indexed: 11/30/2022] Open
Abstract
Foreign body airway obstruction (FBAO), or commonly known as choking, is an extremely dangerous event. The European Resuscitation Council recommends that back blows and abdominal thrusts should be performed for relieving FBAO in conscious adults. Reviewed here evidence suggests that applying a prone or a head-down position increases effectiveness of the above standard approaches to relieve obstruction, due to help of gravity.
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Affiliation(s)
- Artur Luczak
- Canadian Centre for Behavioural Neuroscience, Department of Neuroscience, University of Lethbridge, 4401 University Drive, Lethbridge, AB, T1K 3M4, Canada
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Age-Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk, Modified Food Texture and Autonomy of Choice. Geriatrics (Basel) 2018; 3:geriatrics3040069. [PMID: 31011104 PMCID: PMC6371116 DOI: 10.3390/geriatrics3040069] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 12/02/2022] Open
Abstract
Reductions in muscle mass and strength are well known complications of advancing age. All muscles of the body are affected, including those critical to chewing and swallowing. A diagnosis of frailty and its features of weakness and unintentional weight loss are particularly relevant to the aging swallowing system. Age related changes to eating and swallowing function means that there is a natural tendency for elders to self-select ‘soft’ foods due to loss of dentition and fatigue on chewing. However, it is not well known that tooth loss and poor dental status is associated with increased choking risk, especially as people age. In fact, people over 65 years of age have seven times higher risk for choking on food than children aged 1–4 years of age. Texture modified foods are provided clinically to reduce choking risk and manage dysphagia. Although certain food textures offer greater swallowing safety, they significantly restrict food choice. This commentary paper will highlight age-related changes to the eating and swallowing system, noting especially those that are relevant for frail elders. Swallowing impairments also affect the ability to manage liquids, and aspiration risk in healthy and frail elders is also discussed. Modified food textures that are most often recommended by clinicians to maintain sufficient oral intake and reduce choking risk will be described, while also highlighting the nutritional challenges associated with these foods and offering some solutions. The ethical challenges associated with balancing the autonomy of choice of food textures with swallowing safety will be addressed.
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Aquila I, Gratteri S, Sacco MA, Nuzzolese E, Fineschi V, Frati P, Ricci P. Could the screening for correct oral health reduce the impact of death due to bolus asphyxia in adult patients? A forensic case report. Med Hypotheses 2017; 110:23-26. [PMID: 29317062 DOI: 10.1016/j.mehy.2017.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION "Bolus death" or "Café Coronary syndrome" refers to death due to asphyxia caused by an occlusion of the upper airways due to food. In this kind of asphyxia, the food bolus obstructs the larynx or the bronchial branches. This kind of event often affects subjects with acute intoxication due to alcohol or drugs, or with edentulism and with neurological or psychiatric diseases. CASE REPORT An elderly woman, suffering from schizophrenia, was found dead in her house due to food bolus asphyxia. The post-mortem toxicological analysis on the deceased's biological fluids revealed the presence of tricyclic antidepressants, antipsychotics and neuroleptics. Study of the oral cavity showed the presence of partial edentulism and periodontal disease. HYPOTHESIS We hypothesize that this kind of asphyxia in adults can be prevented. We believe that there are two major preventable factors: edentulism and salivation disorders in elderly and neuropsychiatric patients. The primary prevention of these pathologies would deal with the basic physician, similarly to other screenings already effectively in place. CONCLUSIONS It is possible to prevent fatal asphyxia in subjects who suffer from this kind of diseases through appropriate screening. This prevention strategy would greatly reduce the amount of choking deaths in adults.
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Affiliation(s)
- Isabella Aquila
- Chair of Legal Medicine, University "Magna Graecia" of Catanzaro, Italy.
| | - Santo Gratteri
- Chair of Legal Medicine, University "Magna Graecia" of Catanzaro, Italy
| | - Matteo A Sacco
- Chair of Legal Medicine, University "Magna Graecia" of Catanzaro, Italy
| | - Emilio Nuzzolese
- Chair of Legal Medicine, University "Magna Graecia" of Catanzaro, Italy
| | | | - Paola Frati
- Chair of Legal Medicine, University "La Sapienza" of Rome, Italy
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Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, Duivestein J, Kayashita J, Lecko C, Murray J, Pillay M, Riquelme L, Stanschus S. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia 2017; 32:293-314. [PMID: 27913916 PMCID: PMC5380696 DOI: 10.1007/s00455-016-9758-y] [Citation(s) in RCA: 458] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/08/2016] [Indexed: 12/20/2022]
Abstract
Dysphagia is estimated to affect ~8% of the world's population (~590 million people). Texture-modified foods and thickened drinks are commonly used to reduce the risks of choking and aspiration. The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures. A multi-professional volunteer committee developed a dysphagia diet framework through systematic review and stakeholder consultation. First, a survey of existing national terminologies and current practice was conducted, receiving 2050 responses from 33 countries. Respondents included individuals with dysphagia; their caregivers; organizations supporting individuals with dysphagia; healthcare professionals; food service providers; researchers; and industry. The results revealed common use of 3-4 levels of food texture (54 different names) and ≥3 levels of liquid thickness (27 different names). Substantial support was expressed for international standardization. Next, a systematic review regarding the impact of food texture and liquid consistency on swallowing was completed. A meeting was then convened to review data from previous phases, and develop a draft framework. A further international stakeholder survey sought feedback to guide framework refinement; 3190 responses were received from 57 countries. The IDDSI Framework (released in November, 2015) involves a continuum of 8 levels (0-7) identified by numbers, text labels, color codes, definitions, and measurement methods. The IDDSI Framework is recommended for implementation throughout the world.
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Affiliation(s)
- Julie A Y Cichero
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia.
- School of Pharmacy, Pharmacy Australia Centre of Excellence (PACE), The University of Queensland, 20 Cornwall St, Brisbane, QLD, 4102, Australia.
| | - Peter Lam
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
- Peter Lam Consulting, Vancouver, BC, Canada
| | - Catriona M Steele
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ben Hanson
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Department of Mechanical Engineering, University College London, London, UK
| | - Jianshe Chen
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Zhejiang Gongshang University, Hangzhou, China
| | - Roberto O Dantas
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Janice Duivestein
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Access Community Therapists, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jun Kayashita
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Department of Health Sciences, Prefectural University of Hiroshima, Hiroshima, Japan
| | - Caroline Lecko
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- National Health Service Improvement, London, UK
| | - Joseph Murray
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Ann Arbor Veterans Affairs, Ann Arbor, MI, USA
| | - Mershen Pillay
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Speech Pathology, School of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
- Manchester Metropolitan University, Manchester, UK
| | - Luis Riquelme
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Department of Speech-Language Pathology, New York Medical College, Valhalla, NY, USA
- Barrique Speech-Language Pathology at Center for Swallowing & Speech-Language Pathology, New York Methodist Hospital, Brooklyn, NY, USA
| | - Soenke Stanschus
- International Dysphagia Diet Standardisation Initiative (IDDSI) Working Committee, Brisbane, QLD, Australia
- Swallowing and Speech Pathology, Hospital zum Heiligen Geist, Kempen, Germany
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Postmortem computed tomography suggests the possibility of fatal asphyxiation by mochi, Japanese rice cakes: A case report of postmortem radiologic findings. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jofri.2015.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Singh RR, Nayak R. Impact of FDA Black Box Warning on Psychotropic Drug Use in Noninstitutionalized Elderly Patients Diagnosed With Dementia. J Pharm Pract 2016; 29:495-502. [DOI: 10.1177/0897190015579451] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: The study seeks to investigate the impact of Food and Drug Administration's black box warning (BBW) on the use of atypical antipsychotics (AAP) and nonantipsychotic psychotropic alternatives in noninstitutionalized elderly population diagnosed with dementia. Method: The Medical Expenditure Panel Survey (2004 through 2007) was utilized as the data source. Medication use in elderly patients (≥65 years) was defined as taking at least 1 medication for dementia. We performed a statistical comparison of prewarning (2004-2005) and postwarning (2006-2007) periods with respect to AAP and nonantipsychotic psychotropic use to examine the impact of labeling changes. Results: A bivariate analysis did not yield statistically significant change in either the AAP or nonantipsychotic psychotropic use, pre- versus postwarning. However, multivariate logistic-regression analyses revealed greater odds for antidementia (odds ratio [OR] = 1.976, P = .0195) and benzodiazepine (OR = 3.046, P = .0227) medication use in postwarning period compared to the prewarning period. Conclusion: The regulatory warnings and labeling changes regarding off-label use of AAPs in dementia treatment showed minimal impact on their actual use in noninstitutionalized populations. A corresponding increase in the use of nonantipsychotic psychotropics explains that BBW might have resulted in a compensatory shift in favor of benzodiazepines and antidementia medications. Additional research should be conducted to examine the long-term impact of BBW on antipsychotic prescribing changes.
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Affiliation(s)
- Rakesh R. Singh
- Department of Health Outcomes and Pharmacy Practice, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Rajesh Nayak
- Department of Pharmacy Administration and Allied Health Sciences, College of Pharmacy and Health Sciences, St John’s University, Queens, NY, USA
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Affiliation(s)
- J.A.Y. Cichero
- School of Pharmacy, The University of Queensland; Brisbane QLD Australia
- The Wesley Hospital; Brisbane QLD Australia
- International Dysphagia Diet Standardisation Initiative; Brisbane QLD Australia
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12
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An autopsy approach to bolus deaths. J Forensic Leg Med 2016; 42:82-7. [PMID: 27289267 DOI: 10.1016/j.jflm.2016.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 01/09/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The term "bolus death" or "cafe coronary" refers to a misplaced larynx or laryngeal inlet by foreign bodies, in most cases by unchewed pieces of food such as meat, sausage, or fruit. The pathophysiologic mechanism of death is still debatable - sudden reflex cardiac arrests and asphyxial suffocations are implicated. In particular, children, alcoholics, and persons with brain-related damages belong to this risk group. A defective dentition is also associated with the risk of bolus deaths. AIM The aim of the study was to supplement existing literature by evaluating cases of bolus deaths and determining the most likely mechanism of death in a large autopsy sample. MATERIAL Among 31,647 autopsies, 59 cases of cafe coronary syndrome were identified and evaluated: 38 male adults and 21 female adults between the ages of 26 and 89 years. METHODS A retrospective analysis of autopsies performed in the Institutes of Forensic Medicine in Rostock (1990-2014) and Munich (1990-1999) was conducted. Autopsy findings, circumstances of death, police investigations, preexisting conditions, dentition, and toxicological investigations were recorded. Then, based on the presence or absence of selected findings and surrounding circumstances, conclusions on the mechanism of death were drawn. RESULTS In eighty-six percent (86%), boluses of meat and sausage or meat-like chunks were observed. Of the forty-nine victims, 22 (42%) had elevated blood alcohol levels (>0.5‰) with blood alcohol concentration (BAC) levels of >0.73‰ to <3.99‰. Of the nonalcoholized decedents, 63% had neurological disorders and 11% had preexisting cardiac conditions. CONCLUSIONS Detecting potential bolus events upon autopsy and the resulting mechanism of nonnatural deaths are of great importance. Therefore, the medical history, resuscitation protocol, and detailed description of the scene of death are essential. Upon autopsy, the type and position as well as size and weight of the bolus and dental status of the victims should be documented in a standardized manner. Additional toxicological investigations are necessary.
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Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest. Case Rep Crit Care 2016; 2016:1329234. [PMID: 27006837 PMCID: PMC4781940 DOI: 10.1155/2016/1329234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 01/28/2016] [Accepted: 02/03/2016] [Indexed: 11/23/2022] Open
Abstract
Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct diagnosis requires a high level of clinical suspicion combined with a detailed history and exam. Sudden cardiac arrest after FBA may occur secondary to asphyxiation. We present a 48-year-old male with no history of cardiac disease brought to the emergency department after an out-of-hospital cardiac arrest (OHCA). The patient was resuscitated after 15 minutes of cardiac arrest. He was initially managed with therapeutic hypothermia (TH). Subsequent history suggested FBA as a possible etiology of the cardiac arrest, and fiberoptic bronchoscopy demonstrated a piece of meat and bone lodged in the left main stem bronchus. The foreign body was removed with the bronchoscope and the patient clinically improved with full neurological recovery. Therapeutic hypothermia following cardiac arrest due to asphyxia has been reported to have high mortality and poor neurological outcomes. This case highlights the importance of early identification of FBA causing cardiac arrest, and we report a positive neurological outcome for postresuscitation therapeutic hypothermia following cardiac arrest due to asphyxia.
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Hiding in Plain Sight: Clinically Unrecognized Fatal Tooth Asphyxia Revealed by the Forensic Autopsy. Am J Forensic Med Pathol 2016; 37:14-20. [PMID: 26726967 DOI: 10.1097/paf.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fatal asphyxia by choking whether by food or foreign material remains an uncommon occurrence affecting mainly those at the extremes of age and with variable and sometimes misleading clinical presentations. Prompt clinical recognition of impending airway obstruction afforded by complete physical examination and assessment is paramount for prevention of morbidity and mortality in these cases. In the elderly, a death initially presenting with sudden cardiorespiratory collapse may be erroneously certified as due to natural disease without performance of an autopsy. Fortunately, deaths subsequent to cardiorespiratory collapse, where results of the clinical work-up fail to identify an etiology and medical history is insufficient, are reportable, falling under the jurisdiction of the medical examiner/coroner. The performance of an autopsy in the evaluation of a sudden death arising after hospitalization in which the etiology remains unclear can provide valuable information to our clinical colleagues that they can apply to more timely diagnosis and treatment. Furthermore, the forensic autopsy offers clarification and answers to questions of medicolegal importance. This is particularly true for choking deaths. Presented is a choking death after tooth aspiration whereby the forensic autopsy provided specific anatomic correlation to the clinical clues not recognized before death and provided the true cause of death.
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Bhadauria RS, Gupta R, Khanna S, Chamoli S, Sinha A. A case of hoarseness of voice. Med J Armed Forces India 2015; 71:S499-501. [DOI: 10.1016/j.mjafi.2014.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 12/28/2014] [Indexed: 11/17/2022] Open
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Chung CH, Lai CH, Chien WC, Lin CH, Cheng CH. A population-based study of inpatients admitted due to suffocation in Taiwan during 2005-2007. ACCIDENT; ANALYSIS AND PREVENTION 2013; 50:523-529. [PMID: 22717228 DOI: 10.1016/j.aap.2012.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 05/23/2012] [Accepted: 05/28/2012] [Indexed: 06/01/2023]
Abstract
The objective of this study was to analyze the epidemiology and factors associated with prognoses (inpatient fatality) of patients hospitalized due to suffocation. Data from 2005 to 2007 were sourced from the Taiwanese National Health Insurance Research Database. Suffocation was defined as E911-E915 according to the ICD-9-CM classification. In total, 4062 hospitalizations occurred in Taiwan due to suffocation from 2005 to 2007, with an inpatient fatality rate of 6.5%. Among hospitalizations due to suffocation, "foreign body unintentionally entering other orifice", "food causing obstruction", and "other object causing obstruction" accounted for 58.4%, 17.9%, and 11.0%, respectively. There were more cases of male inpatients than female patients; in terms of age, infants under 1 year old and the elderly aged 65 and over had the highest rates of hospitalization. Factors associated with inpatient fatality included "age", "cardiac arrest", "received surgery or procedure", "acute respiratory failure", "anoxic brain damage", and "foreign body in larynx". Infants and the elderly were high-risk groups for hospitalization as a result of suffocation; the dominant cause among inpatient fatality was "food causing obstruction", which accounted for 22.2% of cases. Medical institutions should focus on the factors associated with inpatient fatality to improve prognoses and decrease the fatality rates of inpatients.
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Affiliation(s)
- Chi-Hsiang Chung
- Graduate Institute of Life Sciences, National Defense Medical Center, Taiwan, Republic of China.
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Blain H, Bonnafous M, Grovalet N, Jonquet O, David M. The table maneuver: a procedure used with success in four cases of unconscious choking older subjects. Am J Med 2010; 123:1150.e7-9. [PMID: 20870197 DOI: 10.1016/j.amjmed.2010.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 06/26/2010] [Accepted: 07/03/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND confronted with an unconscious choking victim, it is recommended to call an ambulance and start mouth-to-mouth and cardiopulmonary resuscitation (CPR). We describe a procedure called the "table maneuver" that was successful in relieving foreign-body airway obstruction in 4 cases of choking in unconscious elderly patients over a 6-year period in the same long-term care facility. METHODS the patients ranged in age from 70 to 89 years and were cyanosed and unconscious after choking while having a meal at a table. In a first attempt in 1 case, after failure of the Heimlich maneuver in 2 cases, and in combination with CPR in 1 person in cardiac arrest, the choking person was laid down on the table in prone position with the head facing downwards, with the arms hanging over the table, and then given sharp blows between the scapulas with the heel of the hand. RESULTS after a few back blows in 3 cases, and in combination with CPR in 1 case, the patients forcefully spit out the foreign body (pieces of beets, Brussels sprouts, a croissant soaked in milk, or pieces of banana) without either early or late complications. CONCLUSION these 4 case reports show that the table maneuver is a potentially life-saving technique that could be applied to patients with severe choking caused by foreign-body airway obstruction who fail to respond to the Heimlich maneuver and other conventional treatments.
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Affiliation(s)
- Hubert Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, and EUROMOV, University Montpellier 1, Montpellier, France.
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Inamasu J, Miyatake S, Tomioka H, Shirai T, Ishiyama M, Komagamine J, Maeda N, Ito T, Kase K, Kobayashi K. Cardiac arrest due to food asphyxiation in adults: Resuscitation profiles and outcomes. Resuscitation 2010; 81:1082-6. [DOI: 10.1016/j.resuscitation.2010.04.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 04/09/2010] [Accepted: 04/28/2010] [Indexed: 10/19/2022]
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Boghossian E, Tambuscio S, Sauvageau A. Nonchemical Suffocation Deaths in Forensic Setting: A 6-Year Retrospective Study of Environmental Suffocation, Smothering, Choking, and Traumatic/Positional Asphyxia. J Forensic Sci 2010; 55:646-51. [DOI: 10.1111/j.1556-4029.2010.01351.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Oesterhelweg L, Bolliger SA, Thali MJ, Ross S. Virtopsy: Postmortem Imaging of Laryngeal Foreign Bodies. Arch Pathol Lab Med 2009; 133:806-10. [DOI: 10.5858/133.5.806] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2008] [Indexed: 11/06/2022]
Abstract
Abstract
Context.—Death from corpora aliena in the larynx is a well-known entity in forensic pathology. The correct diagnosis of this cause of death is difficult without an autopsy, and misdiagnoses by external examination alone are common.
Objective.—To determine the postmortem usefulness of modern imaging techniques in the diagnosis of foreign bodies in the larynx, multislice computed tomography, magnetic resonance imaging, and postmortem full-body computed tomography–angiography were performed.
Design.—Three decedents with a suspected foreign body in the larynx underwent the 3 different imaging techniques before medicolegal autopsy.
Results.—Multislice computed tomography has a high diagnostic value in the noninvasive localization of a foreign body and abnormalities in the larynx. The differentiation between neoplasm or soft foreign bodies (eg, food) is possible, but difficult, by unenhanced multislice computed tomography. By magnetic resonance imaging, the discrimination of the soft tissue structures and soft foreign bodies is much easier. In addition to the postmortem multislice computed tomography, the combination with postmortem angiography will increase the diagnostic value.
Conclusions.—Postmortem, cross-sectional imaging methods are highly valuable procedures for the noninvasive detection of corpora aliena in the larynx.
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Affiliation(s)
- Lars Oesterhelweg
- From the Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Switzerland. Dr Oesterhelweg is now with the State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Berlin, Germany
| | - Stephan A. Bolliger
- From the Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Switzerland. Dr Oesterhelweg is now with the State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Berlin, Germany
| | - Michael J. Thali
- From the Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Switzerland. Dr Oesterhelweg is now with the State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Berlin, Germany
| | - Steffen Ross
- From the Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Switzerland. Dr Oesterhelweg is now with the State Institute of Legal Medicine Berlin, Senate Administration for Health, Environment and Customer Protection, Berlin, Germany
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Oliveira RN, Silva RHA, Boldrini SDC. Pericial analysis of a dental element found inside food used for human consumption. J Forensic Leg Med 2008; 15:269-73. [PMID: 18423364 DOI: 10.1016/j.jflm.2007.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 08/07/2007] [Accepted: 10/08/2007] [Indexed: 10/22/2022]
Abstract
The field of forensic dentistry embodies the human identification in a lot of conditions. A case is described when a tooth-like object was found in a pork sausage. A lawsuit was filed against the food company and the possible dental element was analysed. The tests used to analyze the case were: scanning electronic microscopic exam, radiographic exam and compared anatomy. The results confirmed that the object found in the sausage pack was a dental element from an adult pig; which had the potential for problems like asphyxia or contamination. The case illustrates one facet of forensic dentistry in Brazil.
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Affiliation(s)
- Rogério Nogueira Oliveira
- Social Dentistry Department, Dental School - USP, Avenida Prof. Lineu Prestes, 2227, Cidade Universitária, 05508-000 São Paulo, SP, Brazil.
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Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutr Diet 2007. [DOI: 10.1111/j.1747-0080.2007.00153.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Death from choking is the fourth most common cause of unintentional-injury mortality, but little data are published on causes or locations of these episodes. These deaths typically are peaked at the extremes of age, with young children and the elderly having the greatest rate of fatal choking. Our objective was to characterize the causes of fatal airway obstruction in adults. The San Diego County Medical Examiner's database was searched for deaths attributed to choking in decedents 18 years and older during the 10-year period from 1994 to 2004. Data were abstracted regarding the underlying medical conditions, items choked on, location of the choking, and treatments involved in the individual cases. We found 133 victims who died from choking, with 14% having using alcohol or other sedatives and 55% having a documented neurological deficit or anatomic difficulty with swallowing. The most common specified food objects that victims choked on were meat products, and 45% occurred at home, followed by 26% at supervised facilities, and 14% at restaurants. Of the 19 choking episodes occurring in restaurants, only one employee was documented to attempt a resuscitative effort. Most victims who choked to death had an underlying neurological deficit, and occurred at home or supervised facilities appear to have an appropriate initial-response intervention.
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Affiliation(s)
- Laura Dolkas
- Department of Emergency Medicine, San Diego Medical Center, University of California, San Diego, CA 92103, USA
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Wick R, Gilbert JD, Byard RW. Café coronary syndrome-fatal choking on food: an autopsy approach. ACTA ACUST UNITED AC 2005; 13:135-8. [PMID: 16356749 DOI: 10.1016/j.jcfm.2005.10.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 10/22/2005] [Indexed: 11/30/2022]
Abstract
To examine the characteristic features of fatal food asphyxia and to develop an autopsy approach to such cases a retrospective study of autopsy files was undertaken at Forensic Science SA (Adelaide, Australia) over a 10 year period from 1993 to 2002 for all cases of food asphyxia/café coronary syndrome. Forty-four cases were identified (M;F=21:23), with one infant (11 mths) and 43 adults (30-96 yrs; mean 68.9 yrs), with a preponderance of victims (57%) aged between 71 and 90 yrs. Deaths occurred in nursing homes (N=22) cases, at home (N=11) and in restaurants (N=4). Twenty-seven of the victims (61%) had histories of neurological or psychiatric disorders such as dementia (N=8), schizophrenia (N=6), Alzheimer disease (N=4), atherosclerotic cerebrovascular disease (N=4), mental impairment (N=2), multiple sclerosis (N=1), Parkinson disease (N=1) and obsessive-compulsive disorder (N=1). Twenty-seven cases (61%) were described as either edentulous or having significant numbers of teeth missing. Toxicological evaluation of blood revealed alcohol and a variety of psychotropic prescription medications in 19 cases. Sudden collapse during or shortly after a meal should always raise the possibility of café coronary and the autopsy examination should not only attempt to demonstrate airway occlusion by a bolus of food, but also to identify or exclude underlying neurological disease. Such cases may raise issues concerning adequacy of care and appropriateness of medication. The diagnosis of café coronary syndrome can only be made with confidence after the clinical history and circumstances of death have been clearly established, impacted material has been demonstrated in the airway at autopsy (or recorded by those attempting resuscitation), risk factors have been identified and other possible causes of death have been excluded.
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Affiliation(s)
- Regula Wick
- Forensic Science SA and Department of Pathology, University of Adelaide, 21 Divett Place, 5000 Adelaide, Australia
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Carrick C, Collins KA, Lee CJ, Prahlow JA, Barnard JJ. Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths. Am J Forensic Med Pathol 2005; 26:275-81. [PMID: 16121086 DOI: 10.1097/01.paf.0000178098.33597.de] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging. We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.
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Affiliation(s)
- Christina Carrick
- Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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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; 28:65-9. [PMID: 15626557 DOI: 10.1016/j.amepre.2004.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND To assess the prevalence of food/foreign body asphyxia in the elderly Viennese population in order to reduce the incidence of these fatal events. METHODS This is an autopsy-based, retrospective study in Vienna, Austria. Participants included all nonhospitalized (n =200) cases of choking in 1984 to 2001, from a total 42,745 consecutive autopsies performed at the Institute of Forensic Medicine. In addition, data from hospitalized adult cases of fatal choking (n =73) in 1984 to 2001, from the mortality registrar of Vienna, were included. RESULTS The nonhospitalized choking victims were analyzed according to age (18 to 64 vs >/=65 years), sex, circumstances of death, and predisposing factors. Hospitalized cases were analyzed according to age, sex, and whether an autopsy was already performed by pathologists at the institution where they died. In the study period, 273 adults died of food/foreign body asphyxia, 73% of them out of the hospital and 27% in hospitals. Food/foreign body asphyxia in the elderly was characterized by a significantly higher asphyxiation of soft/slick foods (p <0.007) with agomphiasis (p <0.002), occurring most frequently during lunch (49%), and in 2.5% during feeding of neurologically impaired. In contrast, younger individuals choked significantly more often on large pieces of foreign material (p <0.002) and showed a significantly higher rate of blood alcohol concentration (p <0.001). CONCLUSIONS This study demonstrates that semisolid foods are the cause of a large number of asphyxiations, especially among the elderly. 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.
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Njau SN. Adult sudden death caused by aspiration of chewing gum. Forensic Sci Int 2004; 139:103-6. [PMID: 15040903 DOI: 10.1016/j.forsciint.2003.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2001] [Accepted: 09/16/2003] [Indexed: 10/26/2022]
Abstract
A case of a fatal foreign material aspiration is presented in the following text. A 24-year-old white male died suddenly. A piece of chewing gum lodged in a pool of frothy fluid was revealed at autopsy. Microscopic examinations revealed atelectasia emphysema, eosinophilic exudate and empty spaces. Blood and urine samples were analyzed, for alcohol and drug use by fluorescence polarization immunoassay (FPIA) on an Abbott AXSYM system. No alcohol or other drugs were detected in blood or urine.
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Affiliation(s)
- S N Njau
- Department of Forensic Medicine and Toxicology, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece.
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Abstract
A choking death of a healthy fisherman, who put a type of live sole between his jaws to free up his hands so that he could collect more fish to put into his basket, is described. The fish squirmed into the larynx and upper trachea and the attempts to rescue the man by his colleagues who used pliers did not succeed, and the man died. Other published cases are reviewed, and risk factors and rescue possibilities discussed.
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Affiliation(s)
- João Pinheiro
- National Institute of Legal Medicine, Coimbra Delegation, Largo da Sé Nova, Portugal.
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Berzlanovich AM, Missliwetz J, Sim E, Fazeny-Dörner B, Fasching P, Marosi C, Waldhoer T, Muhm M. Unexpected out-of-hospital deaths in persons aged 85 years or older: an autopsy study of 1886 patients. Am J Med 2003; 114:365-9. [PMID: 12714125 DOI: 10.1016/s0002-9343(03)00049-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE The aim of this study was to determine the causes of death in the very elderly. METHODS We reviewed 24,081 consecutive autopsies performed over 10 years (1989 to 1998) at the Institute of Forensic Medicine, Vienna, Austria. We focused on autopsies of people aged 85 years or older who died unexpectedly out of hospital. RESULTS The mean age of the 1886 patients (561 men and 1325 women) at the time of death was 88 +/- 3 years (range, 85 to 108 years). Thirty-one percent (n = 588) of those who died were described as having been previously healthy. Cardiovascular disease was the most common cause of death (n = 1465 [77%]). Thirteen percent (n = 246) died of respiratory illness, 5% (n = 94) of gastrointestinal disorders, and 3% (n = 53) of diseases of the central nervous system. Genitourinary and metabolic diseases were uncommon. CONCLUSION Although this out-of-hospital sample is not representative of the entire elderly population, postmortem examinations emphasize the importance of cardiovascular diseases in causing unexpected deaths in older persons.
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Abstract
The problems of assessment of aspiration (foreign bodies, stomach contents, food material) in forensic practical work are well-known, especially if 'suffocation due to aspiration' is considered to be the cause of death (or a concurrent cause of death). In the last 4 years (1998-2001) in the Department of Legal Medicine of the Free University, Berlin, 14 deaths with massive aspirations were investigated. The lethal aspiration cases consisted of seven men and five women between 55 and 91 years old, as well as two children (boy 6 years and girl 19 months old). All but one of the victims had severe neurological alterations (dementia, apoplexia, sequelae of head injuries). In six cases the victims died during or a short time after a meal; they had been fed by the nursing staff, a family member or another caregiver. The witness statements pertaining to clinical symptoms or the course of events ranged from 'no symptoms' to intensive cyanosis, congestion and no clear reactions of distress.
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Affiliation(s)
- Britta Bockholdt
- Department of Legal Medicine, Free University Berlin, Hittorfstrasse 18, 14195 Berlin, Germany.
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