Medical Emergencies
Choking and Aspiration
This page discusses Choking and Aspiration. This should normally not arise if dental treatment is undertaken carefully, but the dental team should always be prepared to manage it correctly if it occurs.
For Hypochlorite (bleach) accidents, see this page in the endodontics section.
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The video focuses on the critical topic of choking, which is a life-threatening situation where a casualty's airway becomes blocked, preventing normal breathing. The primary causes of choking differ by age; in small children, it is often due to small foreign objects, while in adults, food is the most common culprit. The urgency of recognising choking is emphasised, as brain damage can occur within a short time due to a lack of oxygen.
Key signs and symptoms of choking are discussed, including the casualty grasping their throat, showing anxiety or distress, experiencing difficulty with speaking and breathing, persistent coughing, and a change in skin colour (pale or blue). In severe cases, the casualty may become unconscious.
The video outlines the appropriate treatment steps for dealing with a choking emergency. Initially, it's important to calm and reassure the casualty and encourage them to cough. If the mild obstruction persists, the rescuer should position themselves behind the casualty, leaning them forward, and deliver sharp back blows between the shoulder blades. A sequence of five back blows is recommended, followed by checking the mouth for obstructions. If these back blows do not clear the obstruction, the rescuer should then attempt five abdominal thrusts using the Heimlich manoeuvre technique.
Should the situation remain unmanageable after three cycles of back blows and abdominal thrusts, emergency services should be contacted immediately. The procedure includes supporting an unconscious casualty to the floor and initiating basic life support.
In addition to adult treatment, the video provides guidance on handling choking in infants. The video advises holding the baby in a recovery-like position with the head pointed downwards, performing five back blows followed by five chest thrusts, and repeating this cycle if necessary, until assistance can be sought if the obstruction fails to clear.
Overall, the content emphasises the importance of quick, decisive action in emergency choking situations, ensuring that help is sought promptly if initial interventions are unsuccessful.
If you prefer to view this page as didactic information, rather than as a self assessment, click the arrow below.
Didactic Information:
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When a patient chokes, there is a danger that they may aspirate (inhale) what they are choking on. The risk of choking and aspiration is increased when the mouth is anaesthetised, as the gag reflex is often partially suppressed by local anaesthetics.
The practise of dentistry, which involves placing materials and small instruments into the mouth, and pooling of blood and saliva, obviously carries an innate risk of causing choking.
Signs and Symptoms
Coughing and spluttering
Breathing difficulties, including wheezing and stridor (a high-pitched kind of wheezing).
Paradoxical breathing – where the abdomen and chest are making opposite movements.
Cyanosis – blueness of the skin, nail-beds, mucosa, lips.
Unconsciousness.
Precautions
Use rubber dam wherever possible.
Ensure all small instruments have a floss ligature on them, to aid retrieval if swallowed.
Treat patients either supine (flat), or fully sitting upright. The “halfway back” position may increase the chance of choking. more…
Ensure impression materials are prepared so they will set within a reasonable time. For example, Alginate is very sensitive to the temperature of the mixing water.
Ensure the dental nurse has an unobstructed view of the mouth so (s)he can aspirate effectively. For example, the dentist should hold the mirror at the tip of the handle, not the centre. The nurse should be sitting higher than the dentist, preferably on a stool with a raised foot-ring.
Management
Remove any obvious foreign body from the mouth.
Sit the patient up and let them cough vigorously.
If they are choking on something, are conscious, but can’t cough (or coughing is ineffective), this signifies a severe airway obstruction. Deliver five firm blows to the upper back, using the heel of the hand. If this is ineffective, give five abdominal thrusts.
If the patient becomes unconscious, start CPR. Chest compressions may help dislodge the item, as well as providing circulatory support.
Aftercare
Following recovery, the patient should be sent to hospital for chest xrays if you suspect any foreign body has been inhaled, such as amalgam, impression material, tooth fragments, or instruments. They should also go to hospital if they are not completely recovered. Salbutamol (see the asthma page) can be used to alleviate wheezing while waiting for an ambulance.
NOTE: the use of abdominal thrusts (Heimlich Manoeuvre) is not recommended by some authorities in some countries, as the evidence base is unclear, and there is risk of causing further injury. The universal choking sign is the main indication for the Heimlich Manoeuvre. This sign consists of the inability to speak, breathe, or cough while holding both hands up to one's own throat.
Self Assessment
Why is there an increased risk of choking and aspiration during dental treatment?
What are the signs and symptoms?
What precautions should be taken to prevent choking and aspiration?
How would you manage a patient who is choking / aspirating? What after-care would you provide?