Abstract
Choking is a form of asphyxia caused by an obstruction within the air passages. A record-based cross-sectional study involving 30 cases of choking deaths brought for autopsy to the Department of Forensic Medicine, Government T.D. Medical College, Alappuzha, Kerala, India, from 1 January 2013 to 31 December 2022. The commonest age group affected was 0–10 years (26.7%), and there was a male preponderance (73.3%). Time of occurrence aligned with the postprandial phases after the day’s major meals, especially dinner. 46.7% of the victims had pre-existing illnesses like coronary artery disease, seizure disorder, chronic liver disease, inguinal hernia, diabetes mellitus and hypertension. Out of the 20 cases where the choking event was witnessed, only four survived long enough to receive medical assistance prior to death. In 50% of the subjects, the level of obstruction was bronchioles, followed by the laryngeal inlet (33.3%). Choking material was food in 70% of the cases, and the non-food materials included denture, sand, rambutan seed, bottle cap, baby coconut and handkerchief. Lungs showed congestion and oedema in 31.3%, haemorrhages in 14.1%, emphysema in 9.4% and atelectasis in 6.3%. Cerebral oedema was noted in 26.6% of cases. The manner of death was mostly accidental.
Introduction
Choking is the obstruction of the upper aerodigestive tract by food. 1 The internal airways are blocked between the pharynx and the tracheal bifurcation. 2 Obstruction can lead to respiratory distress. Bolus death, also known as Café coronary, is a fatal condition caused by obstruction of the larynx by a bolus of food, leading to reflex cardiac arrest.3, 4 Choking can occur in any age group. 2 It may be seen in children who may have the habit of chewing a variety of non-food materials. Absent or rudimentary dentition and limited chewing skills predispose to choking in infants and toddlers. 5 The peak age is between 2 and 3 years, and most cases occur under 5 years. 6 It is common in elderly people with neurodegenerative diseases like Parkinson’s disease and Alzheimer’s disease. Poor or absent dentition and loosely fitted dentures can predispose to a choking episode. 5 Mental illnesses and false teeth, especially partial dental plates, may also predispose to choking. 2 Choking material could be anything, varying from food materials like a chunk of meat, candy, carrots, nuts, grapes, seeds, plastic or metal parts of toys, the lid of bottles, balloons, coins, dentures, teeth, etc. A soft food bolus can get impacted and result in the death of elderly individuals. Sand, soil, cornmeal or sawdust may be aspirated in rare instances.4, 7 Irrespective of the cause of death, 20%–25% of cases aspirate food. Choking in adults usually involves a food bolus and may be commonly associated with alcohol intoxication. 7 This is due to the activating effect of alcohol on the parasympathetic nervous system and inhibitory effect on the sympathetic system. 4 Blood alcohol level above 150 mg/100 ml and blockage of airways with gastric contents in an individual who are found dead may be assumed to have died due to regurgitation, and evidence such as external vomit on the clothing and surroundings must be looked for in such cases. 2 The rationale of this study on choking fatalities is to explore the underlying causes, associated risk factors, and situational aspects of such deaths to enhance preventive measures and response strategies.
Materials and Methods
This record-based cross-sectional study was conducted in the mortuary wing of the Government T. D. Medical College Hospital, under the Department of Forensic Medicine. The study population comprised all cases of death due to choking that were brought for medicolegal autopsy. The inclusion criteria comprised all documented deaths due to choking which underwent medicolegal autopsy at the Department of Forensic Medicine, Government T.D. Medical College, Alappuzha, between 1st January 2013 and 31st December 2022. Cases with incomplete or missing documentation were excluded. The final sample size consisted of all documented deaths due to choking, brought for autopsy during the specified period.
Data Collection Tools & Procedure
Cases were selected from the postmortem register. The required data were collected from the records kept in the records library, police requisition forms, postmortem detailed notes and postmortem certificates. A proforma was used for recording the necessary data.
Data Analysis
Data were collected and stored as hard copies and later entered into Microsoft Excel. Analysis was done using the Statistical Package for Social Sciences (SPSS) software trial version. During the analysis, qualitative variables were expressed as frequency and percentage, quantitative variables as mean and standard deviation.
Results
Out of the total, 22 cases (73.3%) were males, while 8 cases (26.7%) were females. Among 30 autopsy cases, thick mucus was found in 17 cases (56.7%), blood-stained mucoid fluid in 4 cases (13.3%), and no content in 9 cases (30%). In the oesophagus, regurgitated gastric contents were present in 8 cases (26.6%), while food particles were identified in 4 cases (13.3%). Sand was found in 1 case (3.3%), and in 17 cases (56.8%), no content was observed. Mucosal changes in the air passages revealed congestion in 17 cases (56.7%), haemorrhages in 2 cases (6.6%), and a normal mucosal appearance in 11 cases (36.7%), out of a total of 30 cases examined. Indicators of alcohol presence were noted in 6 cases (20%), which exhibited a detectable smell of alcohol in the stomach contents, and chemical analysis confirmed the presence of ethyl alcohol in 2 cases. No traces of other poisons or drugs were identified in any of the cases. Out of the total of 30 cases, suspected foul play was identified in 5 cases (cases where the manner of death was recorded as ‘suspicious’ in the police requisition), accounting for 16.7%. In contrast, 25 cases (53.3%) showed no indication of foul play. Other results of this study have been elaborated in Tables 1–6 and Figures 1 and 2.
Age Group.
Clinical Presentation (as Documented in the Police Requisition).
Time of Occurrence (as Documented in the Police Requisition).
Activity Prior to Choking (as Documented in the Police Requisition).
Stomach Contents.
Findings in the Internal Organs.
Level of Obstruction.
Choking Material.
Discussion
Out of the 9006 consequent autopsies conducted from 1st January 2013 to 31st December 2022, there were 30 cases (0.33%) of deaths due to choking. Other studies had a study population ranging from 3 to 200, and the study period extended up to 17 years.8–15 The affected age ranged from 5 days to 91 years in the other studies.8–14 Infants and young children may attempt to bite and chew a variety of non-food materials. In one of our cases, a piece of thermocol was found among the stomach contents, even though the choking material was a fruit seed. Young children develop their incisor teeth well before their molars and so can bite off pieces of firm food before being able to masticate them adequately.5, 6 Their dentition being rudimentary and their chewing skills limited make them more susceptible. Poor or absent natural dentition, ill-fitting dentures and neurodegenerative diseases predispose the elderly to choking.5, 16 In our study, there was a male preponderance, which agrees with available studies,8–10, 14 except for one hospital-based study done at Pennsylvania. 12
The time of occurrence of choking incidents aligned with the postprandial period of the day’s major meals.
In other hospital-based studies, pre-existing illnesses like psychiatric and neurodegenerative diseases, such as Parkinson’s disease and Alzheimer’s disease, were seen to be associated with deaths due to choking.10, 12, 15 Ours being an autopsy-based study, non-detection of the above-mentioned diseases may be due to the absence of medicolegal autopsy in most such deaths.
Unlike other studies where the survival period of the victims is not documented, our study found that 66.7% of choking events were witnessed, but only 13.3% of those victims survived long enough to receive medical assistance before death.
Ethyl alcohol was detected in chemical analysis in 2 cases, who had blood alcohol concentrations of 199 and 352 mg per 100 ml, respectively. The presence of alcohol in blood has been reported in 75% of the study subjects by Phanjoubam M. et al. 9
In our study subjects, foreign bodies were seen obstructing the air passage at the level of bronchioles in 50% cases. In contrast to our observation, other studies have recorded the common site as the inlet of larynx,1, 4 bronchi, 9 larynx 11 and trachea. 13 Both food and non-food materials causing choking were encountered in this study. But the case involving the handkerchief was a challenging one, where the manner of death remained undetermined. Other authors have mentioned non-food choking materials like denture, grain, cornmeal, sawdust, coin, candy, carrot, nuts, grapes, toys, balloons, screw and plastic pen components.2–7 Rare cases of aspiration of sand and soil have been documented 4 ; two such cases were encountered in our study. If the victim had an occluded airway and the object or food was removed during resuscitation, the only way to make the diagnosis would be by history; 16 we came across one such case where the plastic cap of a ‘VICKS VapoRub’ bottle was the choking material.
Di Maio has noted agonal aspiration of food in 20%–25% of individuals irrespective of their cause of death.7, 16 Agonal and postmortem redistribution of stomach contents to the upper airway has also been documented.2, 5 Other than the choking material, thick mucus was noted in the air passages in 56.7% of cases. A similar observation has been mentioned in the literature. 17
According to Madea B., in about two-thirds of cases, undigested food particles were found in the stomach and corresponded with the bolus material. This indicates that food ingestion occurred immediately prior to the choking event. The stomach was empty in the other third, where the first mouthful proved fatal. 4
Among our findings in the internal organs—cerebral oedema, pulmonary atelectasis and pallor—congestion and haemorrhages in the myocardium have not been documented in other studies. Duchania and Garg noted petechial haemorrhages on the surface of cerebrum. 13 None of the victims involved in the study showed petechial haemorrhages in the conjunctiva and sclera, which agrees with other authors.4, 7 The internal organ changes noted by other researchers, as well as in our study, included pulmonary congestion & oedema 11 and acute pulmonary emphysema. 4
Foul play was alleged in only 16.7% of cases in our study, whereas a study conducted in Imphal reported suspicion of foul play in every case under consideration. 9
Conclusion
Choking-related fatalities represent a distinct subset of asphyxial deaths, typically resulting from intraluminal airway obstruction, with the bronchioles frequently implicated. While most cases are accidental, the diversity of obstructive materials and the vulnerability of certain populations—such as infants, edentulous elderly individuals, and individuals under the influence of alcohol—highlight the multifactorial nature of this phenomenon. The medicolegal significance of choking is particularly evident in unwitnessed deaths, where the absence of clear external indicators may raise suspicion of foul play, necessitating a thorough and systematic autopsy. Preventive strategies, including appropriate feeding practices, prosthetic management, and public education on emergency interventions such as the Heimlich manoeuvre, are essential to mitigate risk. These findings underscore the need for heightened clinical awareness and forensic diligence in the evaluation and management of suspected choking deaths.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval
The study spanned a period of six months following ethical clearance, which was granted by the Institutional Ethics Committee (Approval No. EC 46/2023, dated 13 March 2023).
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Informed Consent
Not applicable.
