D (2:07)

This episode includes information about the death of individuals as well as children. If this sort of thing upsets you, this is not the episode for you. Welcome to Mayhem in the Morning with your host, Dr. Kendall Crowns. Today's episode, Grapes of Death. Today I'm going to be talking about a fairly common type of case. I see these several times a year and these are individuals dying of choking. Choking is not just caused by food, but it can also be caused by objects as well. It causes greater than 5,500 fatalities every year, making it the fourth leading cause of death in the United States. And almost half of these cases occur at home. It can affect every age group, but most commonly affects people over the age of 65, also known as the elderly, and children, especially under the age of five. It can also affect adults as well, and is often seen in individuals who are intoxicated and in people with mental disorders. Choking occurs when a foreign object lodges in the back of your throat, blocking the larynx and trachea. The object can also forcibly close the epiglottis, which is the cartilaginous flap that closes over your airway when you swallow, so you don't inhale food or fluids. If your airway is completely blocked, you can't breathe, speak, or even cough, and you can feel the object stuck in the back of your throat. You'll keep trying to swallow and trying to make it move, but eventually your brain realizes you aren't getting air in and the clock is now ticking for consciousness. Panic sets in. You grab at your throat with both hands, signaling those around you that something is wrong. Trying to get help, your face, lips and skin begin to turn blue due to lack of oxygen, and in about seven to 10 seconds you go unconscious. And in about another four to five minutes, brain death occurs. If the object can be cleared, breathing can be restored. And the main way to do this is through the use of the Heimlich maneuver, which is a maneuver that was developed in 1972 by an American thoracic surgeon, Dr. Henry Heimlich. It's a life saving technique using abdominal thrusts to expel the obstruction and it has saved millions of lives. 75% of choking cases actually occur in the elderly. The risk increases after the age of 71, making the elderly more likely to choke than any other group in the population. The main culprit is food, usually meat, including the deadly hot dogs. Other things commonly choked on are grapes, nuts, popcorn, hard candy, fruits, vegetables and sticky food, especially peanut butter. The elderly can even choke to death on water. The main reasons for them choking is swallowing difficulties, also known as dysphagia, less saliva and absence of teeth. Dysphagia affects up to one third of adults and is caused by age related muscle weakness or underlying diseases like strokes, dementia or Parkinson's disease. Less saliva is a combination of aging and medication side effects and this can cause difficulty chewing and swallowing. The lack of saliva can make the food more dry and sticky, hard to manage in the mouth and throat. Fewer teeth is also a very common one, and less teeth means bigger Bites, often swallowing things whole. This is the risk factor I see the most in combination with tough, overcooked steaks resulting in large pieces of meat occluding the airways. One case I had was an individual who had no teeth at all. He actually died of a heart attack, not choking. But he had a very interesting finding. The stomach felt like it had hard lumps in it and upon opening contained a unchewed artichoke hearts about 2.5 inches wide. I was surprised he didn't choke on these and he was able to swallow them whole, but I guess anything is possible. A syndrome seen commonly in the elderly and the middle age associated with choking is a cafe coronary syndrome. This syndrome occurs when an otherwise healthy individual collapses during a meal. In the absence of any signs of choking or asphyxia or respiratory distress or neurological symptoms, the person just basically stands up and collapses. People think it's a heart attack and it results in the wrong emergency treatment being administered, meaning the obstruction in the airway is completely missed and the person dies when they could have probably been saved. Typically, the food involved in the cafe coronary syndrome is poorly chewed steak that gets further wedged in the airway as people try and restore breathing. Cafe coronary syndrome is also often seen in the middle age. Poor dentition, taking big bites of food while talking. And they are often intoxicated, typically with alcohol. And this also brings us to another installment of everybody's favorite true crime game show. Is it methamphetamine, women or alcohol? So let's get started. The case was that of a 22 year old male found unresponsive, partially lying in his bed at his residence. His residence was in disarray, lamps were broken, things were thrown around, stuff was torn up. His residence was trashed, but not in a way that suggested he had been in a fight. At autopsy, he was well developed and well nourished. Appeared the reported age. He had abrasions and lacerations about his head, chest and upper and lower extremities. But again, he had been found in a secured residence, so there was no thought of foul play. He exhibited small petechial hemorrhages about his face, which are the little pinpoint hemorrhages that are often seen with strangulation hangings and things of that nature. But they can also be associated with retching and hard gagging internally. It was found that he had pieces of credit card and other debris blocking his airway. These had actually been pressed down on his epiglottis and closed his trachea off. He had basically choked on a credit card. He also had in his stomach multiple foreign bodies, including cell phone parts, wires, earphones, paper and other bits and pieces of credit card. And in his intestines there was an unfired bullet. He was basically a human goat. He exhibited pulmonary congestion as well. So this credit card and other debris had caused him to choke, retch violently, resulting in the particular hemorrhages and eventually dying from asphyxia. And why did he do this? Were there women about? No. Was he drinking? Was it meth? What the toxicology showed was he had methamphetamine on board and no alcohol and no other drugs. So the answer is methamphetamine. The finding of methamphetamine made sense. Sometimes when a person is on methamphetamine, they get itchy, which would account for all his abrasions. It makes people do erratic things. I always think when it doesn't make sense, it's probably methamphetamine. And eating your credit cards just didn't make sense. So his cause of death was choking with a contributing factor of methamphetamine. This case is a little unusual, not just because of the credit card, but usually with the intoxication choking cases, it's typically alcohol. Alcohol impairs a gag reflex, relaxes muscles and reduces the body's ability to react to choking. Other factors in adult choking include laughing and talking with food in your mouth. And yes, your mom was right when she advised you not to talk with food in your mouth. Another factor in adult chokings is mental conditions. A case of one of my colleagues was that of a 40 year old woman who was found unresponsive in her secured residence. She was fully clothed, laying in her bedroom on the floor during a well being check. There was no signs of foul play. The house was secured and she was brought in for autopsy and autopsy. She was a well developed obese female and there was no external evidence of injury. Internally she had no findings except when her throat was examined. They found four latex gloves stuck in the back of her throat. These gloves blocked her airway and caused her to die. But why rubber gloves? The reason why? Well, she had a condition called pica. And let's discuss pica. Pica is a scientific term for craving and subsequent consumption of non food items. It's not an acronym or an abbreviation of a famous physician's last name. Pica is actually the genus and species of the common magpie. Magpies are frequently seen with all sorts of items in their beaks, from chewing gum wrappers to wire hangers. Because of their attraction to sparkly objects, they were thought to be birds with an indiscriminate appetite. And as it turns out, they don't swallow these items, they build their nests with them. But the human condition of desiring non food items was given the name pica in the 6th century because they believed the birds were eating all these odd items. The exact cause of pica is unknown, but it is often linked to nutritional deficiencies, pregnancies, developmental disabilities, mental health conditions and cultural practices. The list of substances consumed by individuals with pica is very long, but earth or dirt is the most commonly consumed substance and out of all these substances, with the exception of ice, they are usually dry, powdery and absorptive, and most of them are rather crunchy. The American Psychiatric association defines pica with four criteria. First, there must be persistent eating of a non nutritive substance for at least a month. Second, this behavior is inappropriate to the person's developmental level. Third, the behavior is not a culturally normative or socially supported practice. And finally, if the behavior occurs at the same time as another DSM diagnosis or other medical disorder, it must be sufficient to require additional attention. The clinical forms of pica share at least four features and these the person with pica appears or reports to be obsessed with eating certain substances. Second, certain physical or sensory properties of the pica items are highly important to the person. Third, in the general population and those with autism spectrum disorder, pica appears to be very powerfully, positively reinforcing for a range of pica related behavior. And finally, both groups of people engage in pica for its short term benefits despite its long term harms. Some segments of the population are more likely to engage in pica than others. Pregnant women easily comprise the largest proportion of consumers, while children form the second largest group. Children most actively seek out clay, paper, chalk, dirt, termite hills, etc. For this reason, pica cannot possibly occur until after the children are over two years of age. The exact cause in any group is again unknown, but it is believed to be triggered by a nutritional deficiency, mental health conditions and developmental factors. I have seen other examples of pica over the years and some rather unusual things have been eaten. But the most unusual one was an individual who ate ballpoint pens and on the day he died he had consumed over 30 ballpoint pens. They filled his entire stomach and they were beginning to be pushed into his intestines and when one perforated his duodenum, which is the beginning of the small intestine, after the stomach and this resulted in fecal material, bacteria, etc. Pouring into his abdominal cavity and that resulted in peritonitis, also known as inflammation of the abdominal cavity. This eventually got into his bloodstream, resulting in sepsis, which is bacteria getting widespread throughout the body with an inflammatory response by the body and that results in septic shock, which can cause tissue damage, organ failure and death, which is what happened in this case. He didn't choke, but instead died from the perforation of his bowel and the resultant peritonitis and sepsis. I don't think he meant to die from consuming the pins, and he had probably done it before. As an aside, the pins that were recovered actually still worked, even though they had been in the stomach for a period of time.

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So now that we've covered the elderly and adults, the that brings us to the other large group of choking victims, which is children. Choking is the leading cause of death in children, with one child dying every five days in the United States and 75% of these occur in children under the age of three. The most common case of pediatric choking is food, with hard candy being the most common culprit. Other common food items are grapes, hot dogs and bones. It's suggested that all grapes be peeled and all hot dogs, especially the tip of the hot dog, be cut into small bite sized pieces. The most common non food item that causes choking are balloons, especially latex balloons and coins. Coins account for more choking incidents, but balloons cause more choking deaths and that is because of the way balloons can easily stretch and mold to the child's airway, making it impossible to breathe. They are also hard to remove from the airway due to their smooth, slippery texture, which thwarts typical rescue methods. Foods and objects can easily block a child's airway because their airway is significantly smaller, shorter and more pliable than an adult. A child's airway measures between 6 to 8 millimeters depending on the age, whereas an adult airway is 20 to 26 millimeters in males and 15 to 22 millimeters in females. Other factors include the child's airway is funnel shaped, the tongue is proportionally bigger and the epiglottis is floppy. The one example I have of a child choking on food is a five month old male. On the day he died he had been crawling and scooting around on the floor like he usually did. He had older siblings and one of them earlier in the day had knocked over a number of items in the kitchen. The mother and the child had diligently cleaned it all up and thought they had gotten everything off the floor but they hadn't. Something had rolled under the stove and the five month old found it. When he was found by the mother he was unresponsive on the floor in the kitchen. In the mid afternoon she started CPR. The other child called 91 1, but the time emergency medical services arrived it was too late. The child had passed away and was pronounced dead at the scene. He was brought to the medical examiner's office for an autopsy. And at his autopsy he was a normal five month old male. No evidence of injury, no congenital abnormalities or birth defects. Internally it was the same. No injuries, no congenital abnormalities. But when I took out his throat structures, he had a maraschino cherry blocking his airway. He had no teeth, so he had swallowed this cherry whole and it had gotten stuck in the back of his throat because his airway was so small and the cherry completely blocked it and he was unable to breathe and probably died within a few minutes. His cause of death, choking, manner of death, accident. Food is the most common reason for pediatric choking and it is one of the things we see the most at autopsy. I've seen other cases of non food related items. I have had one that was actually quite an unusual case of choking. The child didn't die initially from the choking incident, but from a later complication. And what he had swallowed was a cylindrical battery, AAA to be exact. In this case he was a four and a half year old male, he had developmental disabilities and his brother had actually been feeding him Cheetos when he decided to switch and give him a battery, which the child swallowed. He was noticed after swallowing the battery to be choking on something. He was given a drink of water and appeared to be no longer in distress. The next day the child had throat pain, trouble swallowing, fever and was throwing up. He was taken to the hospital and a CT was performed and it showed a battery was stuck in his esophagus. They were surgically able to remove the battery, but the thing about it is when batteries get in your throat, especially button batteries, they can generate an electrical current in the tissue fluids and that produces hydroxide at the negative pole of the battery leading to corrosive mucosal burns. And these burns can erode through the esophagus into the surrounding tissues. And that's what happened. In this case, the child had mucosal injuries, but what had happened was the injuries were deeper than just the esophagus. They had burned through into the surrounding blood vessels near the esophagus and eventually these erosions burst. The child initially started with nosebleeds and as they were trying to control them, he began suddenly vomiting blood and a lot of it. And it happened so quickly they couldn't stop it and he eventually bled out. In a manner of minutes at autopsy. What I found is one ulcer in his esophagus had gone completely through the esophagus and then completely through the aorta, creating what is known as an aortic esophageal fistula, which means there is a bridge between the aorta and the esophagus leading to blood getting into the esophagus. But he also had another erosion from his esophagus into the pulmonary artery, creating another fistula, which means the two biggest vessels of his body, the pulmonary artery and the aorta, had a direct communication to his esophagus and there was no way to stop him. With these two blood vessels being compromised, the child bled out quickly and died. His cause of death was esophageal fistula of his aortic and pulmonary artery due to battery ingestion and the manner of death was accident. So it was not a choking per se, but still something had been swallowed that resulted in his death. In closing, the death of a child is always difficult and upsetting to talk about and to hear about, but the most common manner of death in children is actually accidents. And accidents are almost always preventable. And we can do this by talking about child death and create awareness. And sometimes that awareness can save a life. So if you found this episode helpful, share it, talk about it and get the information out there. Because who knows, the life you might save might be your own or someone you love. And that brings us to the end of the episode. I hope you learned something until the next time.

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