Doctors speak of so-called bolus death when a foreign body that is too large, usually a morsel of food, gets stuck between the larynx and esophagus and triggers a reflex cardiac arrest by irritating the upper laryngeal nerve. The term “bolus death” derives from the Greek word “bolos” – “lump.”
What is a bolus death?
Bolus death is not death by suffocation. Unlike aspiration of a foreign body, in which food or objects enter the airway, in bolus death the foreign body enters the pharynx (gullet) or esophagus (food pipe) by ingestion. If the swallowed chunk then gets stuck in the pharynx or even in the entrance area of the esophagus – the cricoidal cartilage narrowing – and presses on the nerve plexus there, a reflex cardiac arrest can occur. This is because parasympathetic nerves run there, particularly the X. Cranial nerve, called the vagus nerve. The vagus nerve is part of the parasympathetic nervous system, which is responsible for slowing the heartbeat. And if the vagus nerve is extremely irritated by a foreign body, the heart rate may be slowed to the point of cardiac arrest, leading to what is known as bolus death. If the foreign body is stuck in the middle or lower esophagus, it is also an emergency, regardless of whether there are noticeable symptoms. This is because a foreign body stuck in the esophagus can perforate the esophagus.
Causes
If food is not chewed adequately, pieces may be swallowed, either intentionally or accidentally, that are too large to make their way through the larynx (hypopharynx) into the esophagus (esophagus) unimpeded. The following pathomechanism may then occur: the stuck foreign body irritates the laryngeal wall and an excessive vagal response causes cardiac arrest. The superior laryngeal nerve is irritated in the neck, a branch of the vagus nerve, the X. Cranial nerve of the parasympathetic nervous system. This throttles the heart and circulation, causing reflex bradycardia and, above that, cardiovascular arrest. Thus, the victim does not choke on the food. The reflex that leads to sudden cardiovascular arrest is caused by the foreign body lodged in the throat and pressing on the laryngeal nerve plexus. The laryngeal nerve plexus becomes so irritated that the heart rate slows dramatically, leading to cardiac arrest. In healthy adults, swallowing too large a chunk of food is rare but does occur, for example, with a piece of meat. In common parlance, therefore, bolus death is also known as bockwurst death, or swallowing death.
Symptoms, complaints and signs
Unlike impending bolus death, where the patient usually collapses silently, when choking is imminent, the patient tends to gasp for air noisily and shows signs of cyanosis (turns blue from lack of oxygen to the blood). If someone sitting at the table eating suddenly suffers from shortness of breath and grabs their throat, a foreign object is often the cause. If a chunk of food (or even dentures) has become stuck in the throat, there is sudden panic, there is usually no coughing fit, at most coughing with immediate shortness of breath.
Diagnosis and course
Because the affected person becomes unconscious within a few minutes during impending bolus death, the emergency physician’s diagnosis will initially be based on extraneous history from witnesses. As with complete airway obstruction, rapid action is required; this is a life-threatening emergency situation. If time permits, the foreign body can be removed under visualization (laryngoscope) with special forceps. The last resort would be a coniotomy (opening the airway at laryngeal level, popularly and incorrectly called a tracheotomy). However, because the heart can stop beating within seconds of impending bolus death, the first priority is to resuscitate quickly. Several hours after removal of the foreign body (for example, by “Heimlich maneuver”), the patient may still suffer from dysphagia (difficulty swallowing). It is necessary to look to see if there are any internal injuries or if any remnants of the foreign body remain in the larynx or esophagus. This is done by inspection of the mouth and throat and by laryngoscopy (reflection of the larynx) or esophagogastroduodenoscopy (OGD).
Complications
In bolus death, the complication that occurs is death of the patient.In many cases, death cannot be prevented if the nerve is already too badly compressed and cardiac arrest occurs. Should bolus death occur, extremely fast action is necessary to save the patient’s life. In most cases, the affected person faints and becomes unresponsive after only a few minutes. If the emergency physician arrives quickly enough, the foreign body can be removed from the patient using special forceps. However, a tracheotomy is usually performed. The affected person is also resuscitated so that the heart beats again. Usually, there are no further complications after the treatment of bolus death. A few hours after the operation, the patient may experience disturbances and pain during swallowing, which, however, disappear on their own. Swallowing the foreign body can damage the esophagus or the larynx. Pieces of the foreign body can also remain there. These can then be removed surgically. In this case, there are no further complications. In case of bolus death, quick action is necessary. Witnesses can dislodge the foreign body from the patient by giving him strong blows between the shoulder blades. It is also possible to use the so-called Heimlich maneuver.
When should you go to the doctor?
When bolus death is imminent, the affected person’s life can only be saved by extremely rapid action. Therefore, the question of whether and when to see a doctor does not even arise here. At the very first sign of impending bolus death, the emergency physician must be called immediately. If the patient is taken to hospital, he usually dies on the way there. First aid measures must be taken until the emergency physician arrives. These are often decisive for the patient’s survival. Provided the affected person is conscious, he or she should attempt to remove the foreign body by reaching into the throat. If the foreign body cannot be reached, another person must try to loosen it by some firm blows between the shoulder blades. Then it can often be coughed up. Furthermore, an attempt can be made to loosen the foreign body by increasing the pressure inside the abdomen. The so-called Heimlich maneuver is particularly effective, but usually only trained first responders can do it. If the incident occurs in a larger group or in a public place, a targeted search should be made for people who are familiar with this first aid technique.
Treatment and therapy
If a large foreign body is swallowed, it is an emergency situation: the offending foreign body must be removed as quickly as possible. If the patient is conscious, sometimes just reaching into the throat may be sufficient. Otherwise, the first measure should be to try to loosen the foreign body with a few strong blows between the shoulder blades – preferably with the ball of the hand. If this remains unsuccessful after five blows, the “Heimlich maneuver” can be used, up to five strong compressions in the area of the epigastrium. In this maneuver, the first responder stands behind the patient and places his or her own arms around the patient’s upper abdominal area, just below the costal arch. One hand is preferably clenched into a fist, and the second hand clasps the fist. Then a few strong, jerky pulls are made into the patient’s upper abdomen, inward and slightly upward, toward the spine. The desired effect of this sudden intra-abdominal overpressure (pressure increase inside the abdomen) is that the foreign body is pushed out or coughed out. Incidentally, this maneuver can also be used with the patient lying down. The fact that this can also result in internal injuries is a risk that is readily accepted when life is at risk – so inexperienced first responders in particular should not be afraid to use force. If neither the blow between the shoulder blades nor the Heimlich maneuver has any effect, the emergency physician can try to remove the stuck object with special forceps. If this is also not possible, a tracheotomy may be necessary. In the event of cardiovascular arrest, resuscitation must be performed (chest compressions in the center of the chest, at a rate of 100/minute and a pressure depth of five to six centimeters, chest compressions: 30:2 ventilation).
Outlook and prognosis
The outlook and prognosis for bolus death depend on the rate at which the victim is helped.It is possible first aid measures and something that must happen within seconds or a few minutes. If no help is given (removal of the foreign body from the larynx and, if necessary, attempts at resuscitation), the death of the affected person is the consequence. Correspondingly, it can be observed that transport to the hospital by means of an emergency physician is associated with a considerable risk of death, since the few minutes of transport in the event of cardiac arrest are sufficient to cause brain death in the affected person. If, on the other hand, rapid action is taken on the scene, death can be averted in many cases. Here, the type of first aid measures is decisive: First, an attempt should be made to remove the foreign body from the affected person (if he or she is still conscious); in the further course, cardiac massage with ventilation can be performed. Once the foreign body has been removed, the patient can often be resuscitated (provided the pressure on the vagus nerve was not too great) and survives the incident without permanent damage. In the course of initial treatment, the patient may subsequently experience pain in the larynx and difficulty swallowing. However, these pass within hours or days.
Prevention
The best prevention is relaxed eating and thorough chewing of all foods. Be careful with drinks containing larger ice cubes: best enjoyed with a straw. Young children like to put objects in their mouths and run the risk of accidentally swallowing them. Age-appropriate toys without small parts that can be swallowed for the youngest children help prevent this. Patients with clinical pictures associated with swallowing disorders (dysphagia), such as Parkinson’s disease, MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis) or dementia diseases should be carefully observed and supported when eating.
Follow-up
In cases of bolus death, follow-up care is guided by the progression of the condition. If bolus death can be averted by immediate rescue efforts, the first priority is to overcome the associated shock. Any trauma is overcome in the course of trauma therapy and in discussions with other affected persons. Furthermore, the cause of the shortness of breath must be determined. Parents whose child nearly suffered a bolus death should inspect the household for small parts and install safety mechanisms on drawers and cabinets. Check-ups can help rule out bleeding in the throat and other complications. In the case of a fatal bolus death, family members usually need therapeutic support as well. It often takes years to process the trauma. Aftercare may include tapering off any antidepressants. Those affected should also consult regularly with their primary care physician and therapist. Psychological or psychosomatic complaints can still develop years after a trauma. These must be recognized and treated before the physical or mental condition deteriorates further. Thus, there is no one-size-fits-all aftercare for a bolus death. Aftercare is based on the effects of the bolus death and the course of any therapies and medications.
Here’s what you can do yourself
In bolus death, a large foreign body in the throat causes a reflex cardiac arrest. Therefore, the first measure must always be to remove the foreign body. Provided the patient is conscious, he or she should attempt to accomplish this on his or her own by reaching into the throat. However, affected patients often lose consciousness very quickly when bolus death is imminent. In this case, the patient’s survival depends on the quick and efficient response of those present. At the first indication of bolus death, the emergency physician must be called immediately and acute danger to the patient’s life reported. Since victims of bolus death do not suffocate and, as a result, do not gasp or struggle for breath in panic, but often collapse silently, the first signs are often underestimated and mistaken for a simple circulatory weakness. Valuable time is lost as a result, which can end in the death of the person affected. If a person collapses during feeding, it should therefore always be assumed that there is an acute emergency. First aid measures must be taken until the emergency physician arrives. First of all, the patient should be struck hard against the shoulder blades several times with the heel of the hand. If this is not sufficient to remove the foreign body, the Heimlich maneuver (upper abdominal compression) should be used.Thorough chewing of food and adequate attachment of third teeth, which are not infrequently responsible for reflex cardiac arrest, provide the best prevention of bolus death.
