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Better eating habits urged to prevent café coronary syndrome among high-risk groups

22 Jun 2022

  • Eating smaller portions, munching, crumbling and avoiding gulping of food recommended
  • Toothless elderly, infants, children, the very young, the neurologically impaired identified as most at risk
  • Heimlich manoeuvre technique recommended to save choking victims 
BY Ruwan Laknath Jayakody Eating smaller portions of food, munching in prior, crumbling of the food, and avoiding gulping quickly are some measures that edentulous elderly (who lack teeth) must be aware of if deaths from the café coronary syndrome are to be prevented. These recommendations were made in a research article on “A café coronary death due to a ‘banana’” which was authored by P.A.S. Edirisinghe (Senior Lecturer attached to the Kelaniya University’s Medical Faculty’s Forensic Medicine Department) and published in Sri Lanka Journal of Forensic Medicine, Science, and Law 1 (1) in January, 2011. The café coronary syndrome was noted in 1963 by R.K. Haugen in “The café coronary: Sudden deaths in restaurants” where Haugen and others (R.E. Mittleman’s “Fatal choking in infants and children”, and R.E. Mittleman and C.V. Wetli’s “The fatal café coronary. Foreign body airway obstruction”) referred to the obstruction of the upper airway by a bolus of food (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing), witnessed by others, and is not only limited to the elderly but can also occur in very young and neurologically impaired persons in institutions as well. Many of these witnessed cases can be saved with proper, prompt emergency care while awareness of the condition can minimise the deaths that are not witnessed.  Edirisinghe discussed a case which highlights the need to be aware of the condition, especially among the elderly who lack teeth or those who tend to gulp food without mastication (chewing). Case report A 70-year-old edentulous man had dinner with his children the previous night and retired to his room with a banana, given as his dessert, stating that he would eat it later. The next morning, he was found dead in his bed with some secretions from his nose and mouth. Resuscitation was not attempted.  The deceased was an active man who was engaged in farming, but occasionally complained of chest pain aggravated with exertion. He was a non-smoker and a teetotaler. At autopsy, a blob of mucoid (a sticky, gelatinous material of protective substance excreted from the body) secretion, mixed with food particles, was found at the right nostril, while a large piece of banana (7.2 centimetres [cm] into four cm), weighing 21 grams was found firmly lodged in the laryngopharynx (the most caudal [directed toward or situated in or near the posterior part, in this case, of the throat] portion of the pharynx [throat] and is a crucial connection point through which food, water, and air pass). It was moulded to the shape of the laryngeal (area of the throat that contains the vocal cords) anatomy.  The broken surface was facing the epiglottis (a small, movable lid just above the larynx that prevents food and drink from entering the windpipe) and extending up to the vocal cords, obstructing the lumen (inside space of a tubular structure) completely. There was a contusion measuring half a cm into three fourths of a cm in the posterior surface of the epiglottis, surrounded by the congestion of the blood vessels. When the main piece of the banana was dislodged from its position, small pieces of banana were found in the right aryepiglottic (triangular folds of mucous membrane of the larynx) fold.  The banana piece also had the indentation of the epiglottis. The trachea (the long tube that connects the larynx to the bronchi [two large tubes that carry air from the windpipe to the lungs]) and the bronchi contained mucoid secretions mixed with food, but these were not extending to the bronchioles (air passages inside the lungs that branch off like tree limbs from the bronchi).  The stomach contained 400 millilitres of partly digested food. There were three smaller pieces of banana in the stomach. The lungs were normal. Moderate atherosclerosis (a condition that develops when a sticky substance called plaque builds up inside the arteries) was present within the major vessels but the coronaries ostea (the ostia of the left and right coronary arteries are located just above the aortic [a large, cane-shaped vessel that delivers oxygen-rich blood to the body and which starts in the lower left part of the heart and passes through the chest and the abdomen] valve, and when oxygenated blood is pumped into the aorta from the left ventricle [a chamber of the heart which receives blood and from which blood is forced into the arteries], it then flows into the coronary artery ostia) were patent (open and unobstructed) with minimal atherosclerosis. No other significant underlying diseases were present. Blood was not tested for alcohol as the deceased was a teetotaler.  As noted in P. Saukko and B. Knight’s “Suffocation and asphyxia” in “Forensic pathology”, and L.H. Clerf’s “Historical aspects of foreign bodies in the air and food passages”, choking or the obstruction of upper air, i.e between the pharynx and the bifurcation (division into two branches or parts) of the trachea is a well-known phenomenon in forensic literature for many centuries and asphyxiation of food has been recognised as a cause of sudden accidental death.  The café coronary syndrome or death due to the acute obstruction of the upper airway by impacted food while eating was first described in deaths at restaurants where the victim collapsed in front of others, most of the time while trying to swallow a piece of meat, as observed by Haugen. However, later, rare variants have been reported such as coprophagic café coronary (in R.W. Byard’s “Coprophagic café coronary”) and therapy-related café coronary (D.M. Hunsaker and J.C. Hunsaker’s “Therapy related café coronary deaths: Two case reports of rare asphyxial deaths in patients under supervised care”). According to B. Jacob, C. Wiedbrauck, J. Lamprecht, and W. Bonte’s “Laryngologic aspects of bolus asphyxiation bolus death” and M.F. Schmitt and W. Hewer’s “Life threatening situations caused by bolus aspiration in psychiatric inpatients  – Clinical aspects, risk factors, prevention, therapy”, although old age, inadequate mastication due to poor dentition or denture and alcohol consumption are well-known predisposing factors, sedative drugs and anti-Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and co-ordination) drugs are also found to cause increased predisposition.  However, as observed in R.W. Byard’s “Unexpected death due to acute airway obstruction in day-care centres” and “Mechanisms of unexpected death in infants and young children following foreign body ingestion”, the reported predisposing factors for children are inadequate dentition for the food provided and the lack of appropriate eating skills. In their study of 141 autopsy cases, Mittleman and Wetli stated that the commonest type of food involved in free roaming adults was meat while in the institutionalised adult, the commonest agent was soft, friable snack food like bananas, bread, and peanut butter. Per A.M. Berzlanovich, B. Fazeny-Dörner, T. Waldhoer, P. Fasching, and W. Keil’s “Foreign body asphyxia: A preventable cause of death in the elderly”, in an autopsy population of 273, a similar trend was seen, where significantly higher asphyxiation of soft and slick foods with agomphiasis (congenital absence of the teeth, developmental, not due to extraction or impaction, or simply looseness of the teeth), occurring frequently during lunch in the more elderly population in contrast to choking on large pieces of foreign material with a higher rate of blood alcohol concentration in the younger elderly group. Per R.E. Mittleman’s “Fatal choking in infants and children”, children show a different trend compared to the elderly, where commonly asphyxiated food items are hot dogs followed by various items including candy and popcorn to toy rattles and tissue paper.  One of the important issues that a pathologist should be aware of in the diagnosis of café coronary is the exclusion of an aspiration. A simple test of litmus on the acidity will solve the issue, indicating that the secretions found in the lower respiratory tract were not coming from the stomach. However, per H.J. Heimlich and E.A. Patrick’s “The Heimlich manoeuvre: Best technique for saving any choking victim’s life”, if such a situation occurs, awareness of emergency treatment manoeuvres like the Heimlich manoeuvre (deliver five separate back blows between the person’s shoulder blades with the heel of your hand and perform five abdominal thrusts and alternate between giving five blows and five thrusts until the blockage is dislodged) will save many of these lives.


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