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Choking results from obstruction of the trachea by a foreign object. It is the nature of the so‐called “café coronary” that occurs during or shortly after a meal [2]. Although most choking episodes are associated with food, nonedible objects may also cause airway occlusion, particularly in children who may inadvertently aspirate coins, toys, or other objects. Choking can occur with liquids as well as solid substances [3].

Although most obstructions occur in the hypopharynx, a small foreign body may lodge in either bronchus, causing selective obstruction of a lung or lung segment. Because the right bronchus travels more directly off the trachea, most selective obstructions involve the right lung. These tend to be nonfatal and are much more common in the pediatric population (Table 24.1) [4].

Choking may be classified as partial or complete. A complete obstruction impairs the ability to breathe, to talk, and to cough and is an immediate life threat. A partial obstruction results in incomplete occlusion of the airway. In these instances, the individual may still be able to breathe, talk, or cough. A complete occlusion generally mandates immediate intervention such as the Heimlich maneuver, or direct laryngoscopy if ALS personnel are present. Other less invasive maneuvers may be appropriate in individuals with partial obstruction. However, in instances of partial obstruction with compromised air exchange, cyanosis, or loss of consciousness, the rescuer must approach the case as though it involves a complete airway obstruction [5].

The incidence of choking varies with age. For pediatrics, the majority are witnessed by the caregiver. While most of the 12,435 annual ED visits for pediatric choking episodes are nonfatal, there are approximately 175 deaths annually in the United States (Figure 24.1). Children younger than 1 year of age are most likely to choke, with food and liquids causing most of these episodes. While food remains the most common and dangerous, toddlers ages 1 to 4 years have the highest incidence of choking on nonfood items such as coins, latex balloons, or toys. The U.S. Consumer Product Safety Commission has instituted monitoring systems, legislation, and regulations to protect children from nonfood items, but no similar interventions exist for preventing food‐related choking in children or adults. Hard candy, gum, nuts. and hot dogs are just some of the high‐risk foods [3–6].

Choking incidence rises again at age 60 years from concurrent conditions impairing chewing and coordinated swallowing (e.g., Alzheimer dementia, stroke, drinking alcohol, poor dentition, seizure, or Parkinson disease). A prior choking episode significantly increases the chances of future choking [2, 4, 7].

Reviewing the epidemiology of choking victims in these at‐risk groups provides valuable information. Japan found that 10% of fatal choking incidents came from mochi rice and 25% of those deaths occurred in a 3‐day window around the New Year [8]. Community education regarding this danger, coupled with first aid and CPR training for the community and caregivers, led to fewer choking deaths in subsequent years [9].

Table 24.1 Ten leading causes of nonfatal injury emergency department visits 2001–2018

Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

	Age Groups
Rank	1	1‐4	5‐9	10‐14	15‐24	25‐34	35‐44	45‐54	55‐64	65+	All Ages
1	Unintentional Fall 2,312,376	Unintentional Fall 15,301,388	Unintentional Fall 11,351,088	Unintentional Fall 10,580,755	Unintentional Struck by/Against 17,032,229	Unintentional Fall 13,530,813	Unintentional Fall 13,552,907	Unintentional Fall 15,410,152	Unintentional Fall 14,444,824	Unintentional Fall 41,481,463	Unintentional Fall 153,068,392
2	Unintentional Struck by/Against 554,993	Unintentional Struck by/Against 6,295,205	Unintentional Struck by/Against 7,140,347	Unintentional Struck by/Against 10,100,827	Unintentional Fall 15,093,453	Unintentional Overexertion 11,576,122	Unintentional Overexertion 10,229,414	Unintentional Overexertion 7,848,208	Unintentional Struck by/Against 4,311,610	Unintentional Struck by/Against 4,575,935	Unintentional Struck by/Against 77,580,582
3	Unintentional Other Bite/Sting 221,793	Unintentional Other Bite/Sting 2,617,647	Unintentional Cut/Pierce 1,996,896	Unintentional Overexertion 4,994,013	Unintentional MV‐Occupant 13,417,475	Unintentional Struck by/Against 11,385,533	Unintentional Struck by/Against 9,014,836	Unintentional Struck by/Against 7,165,831	Unintentional Overexertion 4,203,366	Unintentional Overexertion 3,566,705	Unintentional Overexertion 57,789,568
4	Unintentional Foreign Body 176,287	Unintentional Foreign Body 2,219,957	Unintentional Other Bite/Sting 1,771,965	Unintentional Cut/Pierce 2,372,524	Unintentional Overexertion 12,495,035	Unintentional MV‐Occupant 10,287,114	Unintentional MV‐Occupant 7,756,641	Unintentional MV‐Occupant 6,304,279	Unintentional MV‐Occupant 3,914,121	Unintentional MV‐Occupant 3,486,633	Unintentional MV‐Occupant 48,532,866
5	Unintentional Fire/Burn 173,831	Unintentional Cut/Pierce 1,469,752	Unintentional Pedal Cyclist 1,473,465	Unintentional Pedal Cyclist 1,852,108	Unintentional Cut/Pierce 8,038,092	Unintentional Cut/Pierce 7,510,102	Unintentional Cut/Pierce 5,972,740	Unintentional Cut/Pierce 4,929,580	Unintentional Cut/Pierce 3,087,781	Unintentional Cut/Pierce 2,481,957	Unintentional Cut/Pierce 37,971,682
6	Unintentional Other Specified 143,148	Unintentional Overexertion 1,368,694	Unintentional Overexertion 1,408,912	Unintentional Unknown/Unspecified 1,683,118	Unintentional Other Specified 4,325,205	Unintentional Other Specified 4,700,730	Unintentional Other Specified 4,487,109	Unintentional Other Specified 4,755,187	Unintentional Other Specified 2,662,423	Unintentional Other Bite/Sting 1,547,982	Unintentional Other Specified 24,073,540
7	Unintentional Inhalation/Suffocation 123,256	Unintentional Other Specified 972,698	Unintentional MV‐Occupant 1,137,559	Unintentional MV‐Occupant 1,489,226	Unintentional Other Bite/Sting 3,077,272	Unintentional Poisoning 3,111,629	Unintentional Poisoning 3,171,028	Unintentional Poisoning 3,505,168	Unintentional Poisoning 2,112,594	Unintentional Poisoning 1,541,853	Unintentional Other Bite/Sting 19,639,678
8	Unintentional Cut/Pierce 110,208	Unintentional Fire/Burn 942,001	Unintentional Foreign Body 1,033,269	Unintentional Other Bite/Sting 1,114,168	Unintentional Unknown/Unspecified 2,803,012	Unintentional Other Bite/Sting 2,955,740	Unintentional Other Bite/Sting 2,483,965	Unintentional Other Bite/Sting 2,304,759	Unintentional Other Bite/Sting 1,543,999	Unintentional Other Specified 1,253,339	Unintentional Poisoning 17,312,604
9	Unintentional Overexertion 97,398	Unintentional Poisoning 794,638	Unintentional Dog Bite 783,098	Unintentional Other Transport 938,352	Unintentional Poisoning 2,618,135	Unintentional Unknown/Unspecified 1,965,206	Unintentional Unknown/Unspecified 1,614,575	Unintentional Unknown/Unspecified 1,379,338	Unintentional Unknown/Unspecified 870,767	Unintentional Other Transport 1,184,565	Unintentional Unknown/Unspecified 13,025,036
10	Unintentional Unknown/Unspecified 95,379	Unintentional Unknown/Unspecified 785,575	Unintentional Other Transport 715,729	Unintentional Dog Bite 623,628	Unintentional Other Transport 2,079,784	Unintentional Other Transport 1,632,185	Unintentional Other Transport 1,370,966	Unintentional Other Transport 1,199,661	Unintentional Other Transport 804,555	Unintentional Unknown/Unspecified 1,142,504	Unintentional Foreign Body 10,499,348

Figure 24.1 Proportions of unintentional injury deaths in the United States 2001‐2018. Unintentional suffocation, including choking, is the fourth leading cause of death from unintentional injury for all age groups.

Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.