Airway Foreign Body - Adult

Quick Answer

Critical: Adult foreign body airway obstruction (FBAO) requires immediate recognition and intervention. For effective cough, encourage coughing only. For ineffective cough, give 5 back blows then 5 chest thrusts, repeating until object cleared or patient unconscious. If unconscious, commence CPR.

Foreign body airway obstruction is a preventable cause of asphyxial death, causing 60-100 deaths annually in Australia. Peak incidence occurs in elderly patients (greater than 65 years) with neurological impairment, poor dentition, or alcohol intoxication. The "Cafe Coronary" describes sudden collapse during eating that mimics myocardial infarction. Management follows ANZCOR Guideline 4 with back blows and chest thrusts (NOT abdominal thrusts). Unconscious patients require CPR with direct laryngoscopy and Magill forceps retrieval. Objects below the cords require bronchoscopy [1,2].

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Upper airway anatomy (pharynx, larynx, glottis), cricothyroid membrane location, oesophageal-tracheal relationship
• Physiology: Mechanics of coughing, intrathoracic pressure generation, hypoxic tolerance and time to cardiac arrest
• Pharmacology: Rarely relevant but know sedation for laryngoscopy if patient combative

Fellowship Exam Relevance

• Written: ANZCOR algorithm, back blows vs chest thrusts rationale, complications of aspiration, imaging approach
• OSCE: May appear as resuscitation station (unconscious choking) or communication station (counselling prevention)
• Key domains tested: Medical Expert (recognition and intervention), Leader (directing first aid response), Communicator (explaining to witnesses/family)

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Key Points

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Epidemiology

Australian/NZ Specific

• Higher incidence in residential aged care facilities due to dysphagia prevalence [6]
• Coronial inquests frequently identify texture-modified diet failures as contributing factors
• Aboriginal and Torres Strait Islander populations may have higher rates of dental disease contributing to risk
• Remote and rural settings face delayed access to emergency services

Risk Factors

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Pathophysiology

Mechanism of Obstruction

Foreign body airway obstruction occurs when an object (usually food in adults) lodges in the hypopharynx, laryngopharynx, or glottis, preventing airflow.

Anatomical Sites of Obstruction:

Supraglottic (above cords) → Most common in acute choking
Glottic (at vocal cords) → High-grade obstruction
Subglottic → May be partial, delayed presentation
Tracheal/Bronchial → Usually right main bronchus (more vertical)

Progression to Cardiac Arrest

Timeline Without Intervention:

0-1 min    → Panic, vigorous cough attempts (if partial), cyanosis onset
1-3 min    → Deepening cyanosis, weakening efforts, loss of consciousness
3-5 min    → Hypoxic brain injury begins, bradycardia develops
4-6 min    → Cardiac arrest (PEA → asystole)
6-10 min   → Irreversible brain damage if not already fatal

Why Chest Thrusts Work

• Generate increased intrathoracic pressure (similar to forced expiration)
• Create pressure gradient to expel object
• Compression depth similar to CPR generates significant airflow
• More effective than abdominal thrusts for objects lodged in upper airway [9]

Cafe Coronary Syndrome

First described by Roger Haugen in 1963, "Cafe Coronary" refers to:

• Sudden collapse during eating
• Often in restaurant or social setting
• Large piece of poorly chewed food (usually meat) lodges at glottis
• Victim cannot speak, cough, or breathe
• Often misdiagnosed as myocardial infarction until autopsy [10]

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Clinical Approach

Recognition

Universal Choking Sign: Patient clutches throat with both hands

When to Suspect FBAO:

• Sudden onset during eating or with object in mouth
• Inability to speak or only mouthing words
• High-pitched stridor or no air movement
• Cyanosis developing rapidly
• Collapse during meal (Cafe Coronary)

Assessment of Severity

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ARC/ANZCOR Algorithm - Guideline 4

Adult Foreign Body Airway Obstruction Algorithm

┌─────────────────────────────────────────────────────────────────┐
│           ASSESS SEVERITY OF OBSTRUCTION                        │
│                                                                  │
│     Is the cough EFFECTIVE or INEFFECTIVE?                      │
└─────────────────────────────────────────────────────────────────┘
                    │                    │
                    ▼                    ▼
        ┌──────────────────┐    ┌──────────────────────────┐
        │  EFFECTIVE COUGH │    │    INEFFECTIVE COUGH     │
        │                  │    │                          │
        │ • Can speak      │    │ • Cannot speak           │
        │ • Loud cough     │    │ • Silent/weak cough      │
        │ • Can breathe    │    │ • Cannot breathe         │
        └──────────────────┘    └──────────────────────────┘
                │                          │
                ▼                          ▼
        ┌──────────────────┐    ┌──────────────────────────┐
        │   ENCOURAGE      │    │      IS PATIENT          │
        │    COUGHING      │    │      CONSCIOUS?          │
        │                  │    └──────────────────────────┘
        │ • Do NOT         │              │          │
        │   intervene      │              ▼          ▼
        │ • Stay with      │         YES          NO
        │   patient        │              │          │
        │ • Monitor for    │              ▼          ▼
        │   deterioration  │    ┌────────────┐  ┌─────────────┐
        └──────────────────┘    │ 5 BACK     │  │ CALL 000    │
                                │ BLOWS      │  │             │
                                │            │  │ START CPR   │
                                │ then       │  │ 30:2        │
                                │            │  │             │
                                │ 5 CHEST    │  │ After each  │
                                │ THRUSTS    │  │ 30, look in │
                                │            │  │ mouth       │
                                │ Repeat     │  │             │
                                │ until      │  │ Remove if   │
                                │ cleared    │  │ visible     │
                                │ or         │  └─────────────┘
                                │ unconscious│
                                └────────────┘

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Management: Conscious Patient

Step 1: Assess and Position

1. Ask: "Are you choking?"

• If they nod or give universal sign, confirm obstruction

2. Assess cough: Effective or ineffective?
3. If effective cough: DO NOT INTERVENE - encourage coughing, stand by

Step 2: Five Back Blows (If Ineffective Cough)

Technique:

1. Stand to the side and slightly behind the patient
2. Support chest with one hand
3. Lean patient forward (head lower than chest if possible)
4. Deliver up to 5 sharp blows between shoulder blades with heel of hand
5. Check after EACH blow - stop if obstruction cleared

Step 3: Five Chest Thrusts (If Back Blows Fail)

Technique:

1. Stand behind the patient
2. Place fist on lower half of sternum (same landmark as CPR)
3. Place other hand over fist
4. Give up to 5 sharp inward and upward thrusts
5. Check after EACH thrust - stop if obstruction cleared

Important Differences from Abdominal Thrusts:

Step 4: Repeat Cycle

• Alternate 5 back blows and 5 chest thrusts
• Continue until:
  • Object is expelled, OR
  • Patient starts breathing effectively, OR
  • Patient becomes unconscious

Special Situations

Pregnant or Morbidly Obese Patients:

• Chest thrusts are the ONLY option (cannot access epigastrium)
• Position arms around chest at level of mid-sternum
• Same technique as for standard chest thrusts

Wheelchair-Bound Patients:

• Perform back blows with patient leaning forward over arm of chair
• Chest thrusts can be done from front or side if needed

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Management: Unconscious Patient

Immediate Actions

1. Call Triple Zero (000) - if not already done
2. Lower patient safely to ground (supine on firm surface)
3. Open airway - head tilt, chin lift
4. Look in mouth - if foreign body VISIBLE, remove it
5. Begin CPR - 30 compressions : 2 breaths

CPR for Choking

Why CPR Works for FBAO:

• Chest compressions generate higher intrathoracic pressures than abdominal thrusts
• Each compression acts as an artificial cough
• May dislodge object from glottis
• Maintains perfusion if cardiac arrest develops

Modifications from Standard CPR:

• After each cycle of 30 compressions, before giving breaths:
  • Look in the mouth for visible foreign body
  • If visible and reachable, remove with fingers
  • If NOT visible, do NOT perform blind finger sweep
• Attempt ventilation - if chest does not rise, reposition and try again
• Resume compressions

Important Note: Do NOT perform blind finger sweeps

• May push object deeper into airway
• Only remove objects that are VISIBLE and easily reachable
• Use fingers or Magill forceps under direct vision

When AED Arrives

• Apply pads as per standard cardiac arrest protocol
• Most choking arrests are PEA or asystole (non-shockable)
• AED will advise "no shock advised"
• continue CPR
• If VF develops (rare), shock as indicated

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ED Management

Initial Approach

Patient Arrives Conscious with Suspected FBAO:

1. Assess severity (effective vs ineffective cough)
2. Continue first aid measures if needed
3. Prepare for advanced airway management
4. Obtain brief history (what, when, witnessed, any intervention)

Patient Arrives Unconscious/In Arrest:

1. Continue CPR
2. Prepare for direct laryngoscopy
3. Have Magill forceps immediately available
4. Call for senior airway support

Direct Laryngoscopy and Magill Forceps

Indications:

• Object visible in oropharynx but not reachable
• BLS maneuvers have failed
• Unconscious patient with ongoing obstruction
• Stridor suggesting glottic or subglottic object

Equipment Required:

Technique:

1. Position patient supine (slight head elevation if cervical spine cleared)
2. Perform direct laryngoscopy with left hand
3. Visualize foreign body at glottis or supraglottic space
4. Use Magill forceps in right hand to grasp object
5. Remove under direct vision
6. Immediately attempt ventilation to confirm clearance
7. If successful, continue airway management as needed

Failed Removal - Surgical Airway

Indications for Cricothyroidotomy:

• Cannot intubate, cannot oxygenate (CICO) situation
• Object wedged at glottis and not removable
• Progressive hypoxia despite best attempts

Cricothyroidotomy bypasses supraglottic obstruction

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Investigations

Immediate

After Initial Stabilization

Imaging Considerations

Chest X-ray Findings:

• Most food is radiolucent (not visible on X-ray)
• Look for:
  • Lobar/segmental atelectasis (if bronchial obstruction)
  • Air trapping (check-valve effect)
  • Aspiration changes
  • Mediastinal air (if oesophageal perforation)

CT Indications:

• Ongoing symptoms despite "cleared" obstruction
• Suspected lower airway foreign body
• Possible oesophageal perforation
• Evaluation for aspiration

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When to Refer for Bronchoscopy

Indications for Bronchoscopy

Types of Bronchoscopy

Pre-Bronchoscopy Management

• Keep patient nil by mouth
• Consider empiric antibiotics if aspiration likely
• Positioning: head-up if possible
• Avoid excessive positive pressure ventilation (may push object deeper)

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Complications

Immediate Complications

Delayed Complications

Post-Obstructive Pulmonary Oedema (POPE)

Post-obstructive pulmonary oedema is a rare but serious complication that can occur following relief of upper airway obstruction. Understanding this condition is important for ACEM candidates.

Pathophysiology:

• During complete obstruction, the patient generates extreme negative intrathoracic pressures (up to -100 cmH2O) trying to breathe
• This creates high transudation pressure across pulmonary capillaries
• When obstruction is relieved, pulmonary oedema develops rapidly
• Similar mechanism to negative pressure pulmonary oedema from laryngospasm

Clinical Features:

• Develops within minutes to hours of obstruction relief
• Pink frothy sputum
• Hypoxia despite patent airway
• Bilateral crackles on auscultation
• CXR shows bilateral pulmonary oedema

Management:

• Supplemental oxygen
• Non-invasive ventilation (CPAP/BiPAP) if available
• Diuretics (furosemide 20-40mg IV)
• Usually self-limiting over 12-48 hours
• May require intubation if severe

Laryngospasm

Laryngospasm may occur as a protective reflex following foreign body removal or instrumentation.

Recognition:

• Stridor or complete silence despite effort
• Oxygen desaturation
• Paradoxical chest movement
• May occur during emergence from sedation

Management:

• 100% oxygen via BVM with PEEP
• Jaw thrust with firm upward pressure at the laryngospasm notch (Larson manoeuvre)
• If persistent: small dose of suxamethonium (0.1-0.5 mg/kg)
• Rarely requires re-intubation

Long-Term Sequelae

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Prevention Counselling

Pre-Discharge Education

Important Note: Prevention counselling is essential and may appear in OSCE communication stations

Key Messages:

1. Chew food thoroughly - especially meat, bread, and sticky foods
2. Avoid talking/laughing while eating - prevents aspiration during swallow
3. Cut food into small pieces - especially for elderly or those with dentures
4. Sit upright when eating - never eat lying down
5. Avoid alcohol excess before meals - impairs protective reflexes
6. Review medications - sedatives increase risk

High-Risk Populations

Aged Care Residents:

• Texture-modified diets for those with dysphagia
• Speech pathology assessment for swallowing
• Supervised mealtimes
• Staff training in FBAO recognition and management

Neurological Impairment:

• Regular swallowing assessments
• Modified food textures
• Upright positioning for feeding
• Consider PEG if severe dysphagia

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Special Populations

Paediatric Considerations

See separate topic: Airway Foreign Body - Paediatric

Key differences:

• Smaller objects (toys, coins, small food items)
• Back blows for infant (face down on forearm)
• Different anatomical considerations (shorter trachea, larger tongue)
• Objects more likely to pass into bronchi in children
• Higher proportion of non-food items (toys, batteries, magnets)

Elderly Patients

Why Elderly Are High Risk:

• Neurological conditions affecting swallow reflex (stroke, Parkinson's, dementia)
• Poor dentition leading to inadequate chewing
• Polypharmacy including sedatives, anticholinergics
• Reduced cough strength and respiratory reserve
• Slower gastric emptying, delayed protective reflexes

Special Considerations:

• Higher mortality due to comorbidities
• More likely to have neurological impairment affecting swallow
• Higher rates of cardiac arrest post-hypoxia
• More fragile - rib fractures more common with thrusts (but still proceed with chest thrusts if needed)
• Consider goals of care discussion if poor prognosis
• May have advance care directives that limit resuscitation

Prevention in Elderly:

Pregnancy

Unique Considerations:

• Chest thrusts ONLY (cannot access abdomen safely)
• Position arms around chest at lower sternum level
• Lower threshold for early intervention due to fetal risk
• Physiological changes increase aspiration risk (delayed gastric emptying, lower oesophageal sphincter relaxation)

If CPR Required:

• Left lateral tilt (15-30 degrees) after 20 weeks gestation
• Manual left uterine displacement if supine
• Consider perimortem caesarean section if no ROSC by 4-5 minutes (if greater than 24 weeks gestation)
• Neonatal team should be alerted early

Third Trimester Specific:

• Difficulty leaning forward for back blows - may need modified positioning
• Chest thrusts may be less effective due to abdominal splinting of diaphragm
• Keep team leader alert to obstetric considerations

Intellectual Disability

Special Considerations:

• Higher rates of dysphagia and choking
• May not be able to communicate effectively
• Behavioural feeding issues (eating too fast, pica)
• Carers may not recognise early signs
• Ensure supported decision-making for care planning

Psychiatric Patients

Risk Factors:

• Antipsychotic medications causing dystonia/dysphagia
• Speed eating behaviour
• Pica (eating non-food items)
• Reduced awareness of risk
• Polypharmacy

Common Objects:

• Non-food items may be ingested intentionally
• Batteries, coins, and sharp objects require different management
• Involve mental health team in prevention planning

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Maori considerations:

• Higher rates of dental disease may contribute to risk
• Remote community settings may delay emergency response
• Cultural considerations for end-of-life discussions
• Involve Aboriginal Health Workers or Liaison Officers
• Higher rates of neurological conditions at younger ages
• Ensure family involvement in decision-making and counselling

Key Health Disparities:

Cultural Safety Considerations:

• Involve family/community in all discussions
• Recognise cultural protocols around death and dying
• Use Aboriginal Liaison Officers when available
• Ensure culturally appropriate follow-up care
• Consider traditional healing practices alongside Western medicine
• Be aware of kinship relationships in decision-making

Rural and Remote Communities:

• Longer delays to definitive care
• Community first aid training is critical
• May need RFDS or helicopter retrieval
• Telemedicine support for remote clinicians
• Equipment availability may be limited

Maori Health Considerations (New Zealand)

Key Points:

• Whanau (family) involvement in all care decisions
• Tikanga (cultural practices) should be respected
• Use of karakia (prayer/blessing) may be important to patient/family
• Maori health providers and liaisons should be involved when possible
• Higher rates of chronic disease contributing to dysphagia risk
• Address health inequities through culturally appropriate prevention programs

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Remote/Rural Considerations

Pre-Hospital

• Bystander intervention is critical - longer ambulance response times
• Community first aid training essential
• Phone CPR guidance from Triple Zero operators
• RFDS activation for retrieval if needed
• May have longer transport times to tertiary care

First Responder Training

Resource-Limited Settings

• May not have bronchoscopy capability
• Stabilise and arrange retrieval if needed
• Telemedicine support for airway management decisions
• Basic equipment should include Magill forceps in all EDs

Essential Equipment for Remote Clinics:

Retrieval Considerations

• Secure airway before retrieval if possible
• If object removed, still consider aspiration risk during transport
• Communicate clearly with retrieval team about events and current status
• RFDS and helicopter services available across Australia
• Pre-alert receiving hospital with clinical details

Telemedicine Support

When to Use Telemedicine:

• Uncertain about need for retrieval
• Complex airway management decisions
• Post-event management advice
• Guidance on bronchoscopy referral criteria

Resources:

• State-based retrieval services (e.g., NSW Ambulance, Retrieval)
• RFDS medical consultation service
• Tertiary hospital emergency departments
• Poison Information Centre (for ingested objects with toxic content)

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Procedural Skills

Magill Forceps Technique - Detailed

Equipment Preparation:

1. Laryngoscope - check light, select blade size (Mac 3 for most adults)
2. Magill forceps - check jaws align and spring function
3. Suction - Yankauer attached, large-bore available
4. Oxygen and BVM at bedside
5. Monitoring - SpO2, ECG connected

Patient Positioning:

• Supine, head neutral or slight extension
• Ramped position if cervical spine cleared
• "Sniffing" position for optimal laryngoscopy view

Step-by-Step Technique:

1. Position yourself at patient's head
2. Open mouth with cross-finger technique if needed
3. Insert laryngoscope blade into right side of mouth
4. Sweep tongue to left
5. Advance blade to vallecula (Macintosh) or under epiglottis (Miller)
6. Lift in direction of laryngoscope handle (not levering on teeth)
7. Visualize foreign body
8. Insert Magill forceps with right hand, curved side down
9. Keep forceps in line of sight (the curve allows this)
10. Grasp foreign body firmly
11. Lock forceps and withdraw smoothly
12. Immediately suction and reassess airway
13. Attempt ventilation to confirm clearance

Tips and Tricks:

Complications of Procedure:

• Dental trauma from laryngoscope
• Oropharyngeal laceration from forceps
• Laryngeal trauma/oedema
• Pushing object deeper
• Aspiration of blood/secretions

When Forceps Removal Fails

Options:

1. Positive pressure ventilation - may push object past cords into bronchus (then bronchoscopy)
2. Surgical cricothyroidotomy - if CICO situation and supraglottic obstruction
3. Emergency bronchoscopy - if object in trachea/bronchi and accessible
4. Tracheostomy - if sustained obstruction and stable enough

Cricothyroidotomy Overview

If foreign body is lodged at or above the level of the vocal cords and cannot be removed, and the patient cannot be ventilated, surgical cricothyroidotomy bypasses the obstruction.

Indications in FBAO:

• Cannot remove object by laryngoscopy/forceps
• Cannot ventilate despite best attempts
• Progressive hypoxia

Key Anatomy:

• Cricothyroid membrane lies between thyroid cartilage and cricoid cartilage
• Located inferior to the obstruction
• Relatively avascular midline approach

See separate topic: Cricothyroidotomy for detailed technique.

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Pitfalls and Pearls

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Viva Practice

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OSCE Scenarios

Station 1: First Aid - Conscious Choking

Format: Procedural/Simulation Time: 11 minutes Setting: Restaurant scene (simulation)

Candidate Instructions:

You are called to assist a diner at a restaurant who appears to be choking. The patient is a 60-year-old man who is conscious but appears distressed and is clutching his throat. Assess the situation and manage appropriately. A bystander (actor) is present. You may talk through your actions.

Examiner Instructions:

• Patient initially has ineffective cough (cannot speak, weak cough)
• After 3 back blows, patient coughs loudly and expels piece of meat
• Patient recovers fully and can speak normally

Actor/Patient Brief:

• Initially clutch throat, shake head when asked "are you choking?"
• Cannot speak, weak coughing attempts
• After third back blow, have violent coughing fit and "spit out" prop
• Recover quickly, say "thank you" in shocked manner

Marking Criteria:

Expected Standard:

• Pass: 6 or more out of 11
• Key discriminators: Correct ANZCOR technique, checking after each intervention, appropriate communication

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Station 2: ED Management - Unconscious Patient

Format: Resuscitation/Procedural Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

A 70-year-old man has been brought in by ambulance after choking at a nursing home. He is currently unconscious, and paramedics are performing CPR. You are the team leader. Manage this patient. Team members (nurse, registrar) are available. Equipment includes full resuscitation trolley with Magill forceps.

Examiner Instructions:

• Initial rhythm: Asystole
• When laryngoscopy performed: Large bolus of food visible at glottis
• After removal: Rhythm changes to sinus tachycardia, pulse present, weak spontaneous breathing

Marking Criteria:

Expected Standard:

• Pass: 6 or more out of 11
• Key discriminators: Uses laryngoscopy + Magill forceps, closed-loop communication, team leadership

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Station 3: Communication - Prevention Counselling

Format: Communication Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

Mr Smith is a 78-year-old man who had a choking episode at dinner. His daughter performed back blows and he coughed up a piece of steak. He is now stable with no ongoing symptoms. He has a history of Parkinson's disease and lives alone. His daughter is present and concerned. Counsel the patient and his daughter about the incident and prevention strategies.

Marking Criteria:

Expected Standard:

• Pass: 6 or more out of 11
• Key discriminators: Identifies Parkinson's as risk factor, recommends swallowing assessment, practical advice

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SAQ Practice

Question 1 (6 marks)

Stem: A 65-year-old woman is choking on food at a restaurant. A bystander has called Triple Zero (000).

Question: List 6 key steps of the ANZCOR algorithm for management of adult foreign body airway obstruction.

Model Answer:

• Assess severity - determine if cough is effective or ineffective (1)
• If effective cough - encourage coughing, do not intervene (1)
• If ineffective cough and conscious - give up to 5 back blows (1)
• If back blows unsuccessful - give up to 5 chest thrusts (1)
• Alternate back blows and chest thrusts until object cleared or patient becomes unconscious (1)
• If unconscious - call for help and commence CPR (30:2) (1)

Examiner Notes:

• Accept: Check after each blow/thrust, look in mouth before breaths during CPR
• Do not accept: Heimlich maneuver, abdominal thrusts, blind finger sweeps

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Question 2 (8 marks)

Stem: A 70-year-old man with dementia is brought from a nursing home following a choking episode. CPR is in progress.

Question: (a) List 4 risk factors for foreign body airway obstruction in this population (2 marks) (b) Describe the ED management approach for this patient (4 marks) (c) List 2 complications that may develop following successful foreign body removal (2 marks)

Model Answer:

(a) Risk factors (0.5 each, max 2):

• Dementia/cognitive impairment
• Dysphagia
• Poor dentition
• Sedating medications
• Inappropriate food texture
• Eating speed/inadequate supervision
• Previous stroke

(b) ED management (1 each, max 4):

• Continue high-quality CPR (30:2)
• Perform direct laryngoscopy to visualize foreign body
• Use Magill forceps to remove object under direct vision
• Give adrenaline 1mg IV/IO every 3-5 minutes (non-shockable rhythm)
• Confirm airway clearance and attempt ventilation
• If ROSC - post-resuscitation care (oxygenation, blood pressure, temperature)
• If no ROSC after prolonged resuscitation - consider termination with family discussion

(c) Complications (1 each, max 2):

• Aspiration pneumonia
• Hypoxic brain injury
• Cardiac arrhythmias
• Rib fractures from CPR/chest thrusts
• Post-obstructive pulmonary oedema

Examiner Notes:

• Accept any reasonable complication
• For management, must mention direct laryngoscopy and Magill forceps for full marks

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Question 3 (6 marks)

Stem: You have successfully removed a piece of meat from the airway of a 55-year-old man who was choking at a BBQ. He is now awake and talking.

Question: List 6 components of your assessment and management after successful foreign body removal.

Model Answer:

• Full examination including oropharynx and chest (1)
• Monitor oxygen saturations and vital signs (1)
• Chest X-ray to assess for aspiration or retained foreign body (1)
• Observe for delayed complications (aspiration, laryngeal oedema) (1)
• Provide prevention counselling (chewing thoroughly, avoiding alcohol, sitting upright) (1)
• Arrange follow-up and safety-netting advice (1)

Examiner Notes:

• Accept: Speech pathology referral if risk factors, lateral neck X-ray, bloods if concerns
• Do not accept: Immediate discharge without observation

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Question 4 (8 marks)

Stem: You are developing a training program for aged care staff on choking prevention and response.

Question: (a) List 4 risk factors for choking that are common in aged care residents (2 marks) (b) Describe the steps of the ANZCOR algorithm for conscious adult choking (4 marks) (c) List 2 reasons why ANZCOR recommends chest thrusts over abdominal thrusts (2 marks)

Model Answer:

(a) Risk factors (0.5 each, max 2):

• Dementia/cognitive impairment
• Dysphagia from stroke or other neurological disease
• Poor dentition or ill-fitting dentures
• Sedating medications
• Parkinson's disease
• Inappropriate food texture
• Speed eating or inadequate supervision

(b) ANZCOR algorithm (1 each, max 4):

• Assess severity - determine if cough is effective or ineffective (1)
• If effective cough - encourage coughing only, do not intervene (1)
• If ineffective cough - give up to 5 back blows, checking after each (1)
• If back blows unsuccessful - give up to 5 chest thrusts, checking after each (1)
• Alternate back blows and chest thrusts until object cleared or unconscious (1)
• If unconscious - call for help, commence CPR (1)

(c) Reasons for chest thrusts (1 each, max 2):

• Lower risk of internal organ injury (liver, spleen, stomach laceration)
• Similar efficacy to abdominal thrusts for object expulsion
• Easier to teach and perform correctly
• Safer for pregnant patients
• More consistent pressure application

Examiner Notes:

• For algorithm, must demonstrate understanding of "back blows first, then chest thrusts"
• Accept any evidence-based reason for chest thrust preference

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Question 5 (6 marks)

Stem: A 45-year-old man presents to ED 2 hours after choking on a piece of steak. He is now symptom-free but wants to be checked.

Question: List 6 components of your assessment and management.

Model Answer:

• History of the event: severity of obstruction, intervention required, current symptoms (1)
• Physical examination: oropharynx, chest auscultation, neck (crepitus) (1)
• Oxygen saturation monitoring (1)
• Chest X-ray to assess for aspiration or complications (1)
• Observe for minimum 1-2 hours for delayed complications (1)
• Prevention counselling and safety-netting advice on when to return (1)

Examiner Notes:

• Accept: Lateral neck X-ray if oropharyngeal symptoms, bloods if aspiration concern
• Accept: Speech pathology referral if recurrent choking or risk factors
• Do not accept: "Send home immediately" without any assessment

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Australian Guidelines

ANZCOR Guideline 4: Airway

Key Points:

• First published 2016, last updated 2021
• Aligns with ILCOR recommendations but adapted for Australian context
• Emphasises chest thrusts over abdominal thrusts (Heimlich)
• Provides clear algorithm for conscious and unconscious choking

Key Differences from AHA:

Key Differences from ERC (European)

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 4: Airway. 2021. Available from: https://resus.org.au
2. International Liaison Committee on Resuscitation (ILCOR). Consensus on Science and Treatment Recommendations for Basic Life Support. 2020.

Epidemiology

3. Australian Bureau of Statistics. Causes of Death, Australia. 2022. Category 3303.0.
4. Australian Institute of Health and Welfare. Injury deaths data. 2023.
5. Kramarow E, Warner M, Chen LH. Food-related choking deaths among the elderly. Inj Prev. 2014;20(3):200-203. PMID: 24003082
6. Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents. Geriatr Nurs. 1999;20(2):77-84. PMID: 10382414

Pathophysiology

7. Duckett SA, Roten RA. Choking. StatPearls. 2023. PMID: 29489227
8. Ekberg O, Feinberg MJ. Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases. Am J Roentgenol. 1991;156(6):1181-1184. PMID: 2028862
9. Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation. 2000;44(2):105-108. PMID: 10767498

Cafe Coronary

10. Haugen RK. The cafe coronary: sudden deaths in restaurants. JAMA. 1963;186:142-143. PMID: 14056526
11. Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA. 1982;247(9):1285-1288. PMID: 7057525

Management

12. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015;95:81-99. PMID: 26477420
13. Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685-S705. PMID: 20956221
14. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A35-A79. PMID: 33098918

Laryngoscopy and Airway Management

15. Finucane BT, Santora AH. Principles of Airway Management. 4th ed. Springer; 2011.
16. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth. 2011;106(5):617-631. PMID: 21447488
17. Falk J, Esclamado R. Management of adult airway obstruction. Otolaryngol Clin North Am. 1995;28(5):935-946. PMID: 8559581

Bronchoscopy

18. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopy. Postgrad Med J. 2002;78(921):399-403. PMID: 12151654
19. Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest. 2002;121(5):1695-1700. PMID: 12006465
20. Mise K, Jurcev Savicevic A, Pavlov N, Jankovic S. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009;23(6):1360-1364. PMID: 18813984

Complications

21. Kikuchi R, Watabe N, Konno T, et al. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med. 1994;150(1):251-253. PMID: 8025758
22. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665-671. PMID: 11228282
23. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J. 2009;102(2):171-174. PMID: 19139679

Prevention

24. Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784-789. PMID: 20713754
25. Cabre M, Serra-Prat M, Palomera E, et al. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39(1):39-45. PMID: 19903775
26. Clave P, Shaker R. Dysphagia: current reality and scope of the problem. Nat Rev Gastroenterol Hepatol. 2015;12(5):259-270. PMID: 25850008

Indigenous Health

27. Australian Indigenous HealthInfoNet. Summary of Aboriginal and Torres Strait Islander health. 2023.
28. Jamieson LM, Armfield JM, Roberts-Thomson KF. Oral health inequalities among Indigenous and non-Indigenous children in the Northern Territory of Australia. Community Dent Oral Epidemiol. 2006;34(4):267-276. PMID: 16856947

Remote/Rural

29. Wakerman J, Humphreys JS. Rural health: why it matters. Med J Aust. 2002;176(10):457-458. PMID: 12064998
30. Australian Government Department of Health. Rural Health Multidisciplinary Training Program. 2023.

Imaging

31. Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg. 1998;33(11):1651-1654. PMID: 9856887
32. Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol. 1989;19(8):520-522. PMID: 2797928
33. Bai W, Zhou X, Gao X, et al. Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies. Pediatr Int. 2011;53(4):515-518. PMID: 21105972

Resuscitation Outcomes

34. Grasner JT, Lefering R, Koster RW, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016;105:188-195. PMID: 27321577

Additional Evidence

35. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189. PMID: 17990843
36. Mu L, Sun D, He P. Radiological diagnosis of aspirated foreign bodies in children: review of 343 cases. J Laryngol Otol. 1990;104(10):778-782. PMID: 2246575
37. Ayed AK, Jafar AM, Owayed A. Foreign body aspiration in children: diagnosis and treatment. Pediatr Surg Int. 2003;19(6):485-488. PMID: 12774247
38. Bloom DC, Christenson TE, Manning SC, et al. Plastic laryngeal foreign bodies in children: a diagnostic challenge. Int J Pediatr Otorhinolaryngol. 2005;69(5):657-662. PMID: 15850687
39. Tokar B, Ozkan R, Ilhan H. Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation. Clin Radiol. 2004;59(7):609-615. PMID: 15208068
40. Passàli D, Lauriello M, Bellussi L, et al. Foreign body inhalation in children: an update. Acta Otorhinolaryngol Ital. 2010;30(1):27-32. PMID: 20559471
41. Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010;111(4):1016-1025. PMID: 20802055
42. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999;115(5):1357-1362. PMID: 10334153
43. Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med. 1990;112(8):604-609. PMID: 2327678
44. Chen CH, Lai CL, Tsai TT, et al. Foreign body aspiration into the lower airway in Chinese adults. Chest. 1997;112(1):129-133. PMID: 9228368
45. Inglis AF Jr, Wagner DV. Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol. 1992;101(1):61-66. PMID: 1728886
46. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. 1994;29(5):682-684. PMID: 8035279
47. Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg. 2006;134(1):92-99. PMID: 16399186

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