Choking
Choking is an obstruction in the process of breathing. Choking, as foreign body airway obstruction (FBAO), is a phenomenon that occurs when breathing is impeded by a blockage inside of the throat or windpipe, resulting in oxygen deprivation. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking often leads to death. This choking was the fourth most common cause of unintentional injury-related deaths in the US in 2011. Over 4,000 choking-related deaths occur in the United States every year. Deaths from choking most often occur in  the very young (children under 2 years old) and in the elderly (adults over 75 years). Foods that can adapt their shape to that of the pharynx (such as bananas, marshmallows, or gelatinous candies) are more dangerous. Providing immediate and appropriate first aid can solve this type of choking (read below). Causes. Choking (in swallowing) happens when a foreign body blocks the airway. This obstruction can be located in the pharynx, the larynx, or the trachea. The blockage is often partial (insufficient air passes through to the lungs), but it can be complete (when the airflow is totally blocked). Foods  that pose a high risk of choking include hot dogs, hard candy, nuts, seeds, whole grapes, raw carrots, apples, popcorn, peanut butter, marshmallows, chewing gum, and sausages. Among children, the most common causes of choking are food, coins, toys, and balloons. In one study, peanuts were the most common object found in the airway of children evaluated for suspected foreign body aspiration. In a 1984 US study, 29% of choking deaths in children were associated with latex balloons, making them the leading cause of choking deaths among children's products. Small, round non-food objects such as balls, marbles, toys , and toy parts are also associated with a high risk of choking death because of their potential to completely block a child's airway. Children younger than age three are especially at risk of choking because they explore their environment by putting objects in their mouths, and they are still developing the ability to chew food completely. Molar teeth, which come in around 1.5 years of age, are necessary for grinding food. Even after molars are present, children continue to develop the ability to chew food completely and swallow throughout early childhood. A child's airway is smaller in diameter  than an adult's airway, which means that smaller objects can cause airway obstruction in children. Infants and young children generate a less-forceful cough than adults, so coughing may not be as effective in relieving airway obstruction. Risk factors of foreign body airway obstruction for people of any age include the use of alcohol or sedatives, procedures involving the oral cavity or pharynx, oral appliances, or medical conditions that cause difficulty swallowing or impair the cough reflex; conditions that can cause difficulty swallowing and/or impaired coughing include neurological conditions such as strokes, Alzheimer's disease, or Parkinson's disease . In older adults, risk factors also include living alone, wearing dentures, and having difficulty swallowing. Children with neuromuscular disorders, developmental delay, traumatic brain injury, and other conditions that affect swallowing are at an increased risk of choking. Children and adults with neurological, cognitive, or psychiatric disorders may experience a delay in diagnosis because there may not be a known history of a foreign body entering the airway. Choking on food is only one type of airway obstruction; others include blockage due to tumors, swelling of the airway tissues, and compression of the laryngopharynx, larynx, or vertebrate trachea in strangulation. Prevention . Warning labels. According to a 1991 study, warning labels are an effective preventive measure against choking accidents. Items that contain many parts may include pieces that are considered choking hazards. Labels may state recommended age ranges (as in the case of children's toys) and warnings to parents to keep certain items out of the reach of children. Warning labels are clearly placed and written, usually including an obvious image. Primary prevention. Choking often happens when large or abundant mouthfuls of food are poorly chewed and swallowed. This risk is minimized by cutting food into moderately sized pieces and chewing  them completely before swallowing. "Any food that may be chewed would have to be chewed" (even the gelatinous food). It is helpful to have some liquid available to drink to make swallowing easier. To swallow well, it is recommended that the neck be in a normal position, with the head looking forward and aligned with the eater's body, and that the eater be seated or standing rather than reclining. Some activities are not very compatible with eating (such as laughing), so eating at the same time increases the risk of choking. Food eaten by the handful (such as popcorn  or nuts) requires chewing with more control than normal. Dangerous foods. The foods that produce the worst cases of choking are those whose shapes adapt to the shape of the pharynx or trachea (such as hot dogs, sausages, bananas and food in blocks). In 2002, candy containing konjac gel was banned by the Food and Drug Administration due to several high-profile choking cases. Other foods are risky because they are dry in the mouth (overcooked meat, sponge cake, cold pizza), which may require drinking liquid, or eating them with purees or sauces. Tough foods are also risky (octopus, cuttlefish , reptiles or big animals), so it is recommended cutting them into smaller chunks or thinner slices, cooking them in a way that softens them, or even eating them together with something that helps the teeth to grind them (like hard bread). It is also easier to choke when eating too fast, which can usually happen in contests, games and celebrations (New Years Eve), etc. Groups at risk. Some population groups have a higher choking risk, such as the elderly, children, persons with disabilities (physically or mentally), people under the effects of alcohol or drugs, people who have taken medications that  reduce the ability to salivate or react, patients with difficulties in swallowing (dysphagia), suicidal individuals, epileptics, and people on the autism spectrum. They may require more assistance to feed themselves, and it may be necessary to supervise them while they eat. People who are unable to chew properly should not be served hard food. In cases where a person is unable to safely eat, food can be given by feeding syringes. People who have taken any medication that reduces saliva should not eat solid food until their salivation is restored. Prevention in babies and children. All young children require care  in eating, and they must learn to chew their food completely to avoid choking. Feeding them while they are running, playing, laughing, etc. increases the risk of choking. Caregivers must supervise children while eating or playing. Pediatricians and dentists can provide information on various age groups to parents and caregivers about what food and toys are appropriate to prevent choking. The American Academy of Pediatricians recommends waiting until 6 months of age before introducing solid foods to infants. Caregivers should avoid giving children younger than 5 years old foods that pose a high risk of choking, such as hot dog  pieces, bananas, cheese sticks, cheese chunks, hard candy, nuts, grapes, marshmallows, or popcorn. Later, when they are accustomed to these foods, it is recommended to serve them split into small pieces. Some foods as hot dogs, bananas, or grapes are usually split lengthwise, sliced, or both. Parents, teachers, and other caregivers for children are advised to be trained in choking first aid and cardiopulmonary resuscitation (CPR). Children readily put small objects into their mouths (deflated balloons, marbles, small pieces, buttons, coins, button batteries, etc.), which can lead to choking. A complicated obstruction for babies is choking on deflated balloons (including  preservatives) or plastic bags. This also includes the nappy sacks, used for wrapping the dirty diapers, which are sometimes dangerously placed near the babies. To prevent children from swallowing things, precautions should be taken in the environment to keep dangerous objects out of their reach. Small children must be supervised closely and taught to avoid putting things into their mouths. Toys and games may indicate on their packages the ages for which they are safe. In the US, children's toy and product manufacturers are required by law to apply appropriate warning labels to their packaging, but toys that are  resold may not have them. Caregivers can try to prevent choking by considering the features of a toy (such as size, shape, consistency and small parts) before giving it to a child. Children's products that are found to pose a choking risk can be taken off the market. Symptoms and signs. The symptoms of choking include: Times in asphyxia. The time a choking victim is still alive without brain damage can vary, but typically: Treatment. Choking is treated with different procedures, which form the airway management. In a general view, this consists of the anti-choking first aid techniques , in the stage of a basic airway management, and of complex methods available for health professionals working in an advanced airway management. Basic treatment (First aid). Basic treatment of choking includes several non-invasive techniques to help remove foreign bodies from the airways. General strategy: "Five and Five". For a conscious choking victim, most institutions (as the American Heart Association and the American Red Cross) recommend the same general protocol of first-aid: asking the victim to "cough strongly", followed by hard "back slaps" and, if they are not effective, applying "abdominal thrusts", that will be changed by "chest thrusts  in case of the victim can not receive pressure on the abdomen (these techniques are detailed further below). If none of these techniques are effective, the protocols recommend alternating more series of back slaps and more series of thrusts (these on the abdomen or chest, depending of the victim), in continual turns of 5 times each one (five and five"). In addition to the victims that can not receive pressure on the abdomen, other victims also require specific procedures (see details further below), mainly the babies and the people with disabilities. When the choking is not being solved, it is  mandatory that somebody calls for emergency medical services, and continuing the administration of first aid until they arrive. The choking can change the colour in the victim's faces. After a while, they would lose consciousness and fall to the ground. Then it is recommended avoiding panic and beginning an anti-choking cardiopulmonary resuscitation (see more details further below). Each one of the techniques in the first aid protocol against choking are detailed below: Cough. If the choking victims can cough, the American Red Cross and the Mayo Clinic recommend encouraging them to stay calm and continue coughing freely. Coughing  with strength is very effective. Between coughs, it may be easier to take air through the nose to refill the lungs. Back blows (back slaps). Many associations, including the American Red Cross and the Mayo Clinic, recommend the use of back blows (back slaps) to aid a choking victim. This technique starts by bending the choking victim forward as much as possible, even trying to place their head lower than the chest, to avoid the blows driving the object deeper into the person's throat (a rare complication, but possible). The bending is in the back, while the neck should  not be excessively bent. It is convenient that one hand supports the victim's chest. Then the back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades. The back slaps push behind the blockage to expel the foreign object out. In some cases, the physical vibration of the action may cause enough movement to clear the airway. Abdominal thrusts (Heimlich maneuver). Abdominal thrusts are performed with the rescuer embracing the belly of the choking victim from behind. Then, the rescuer closes the own dominant hand, grasps it  with the other hand, and presses forcefully with them on the area located between the chest and the belly button of the victim, in a direction of in-and-up. This method tries to create enough pressure upwards to expel the object that obstructs the airway. The strength is not focused directly against the ribs, to avoid breaking them. If the first thrust does not solve the choking, it can be repeated several times. The use of abdominal thrusts is not recommended for infants under 1 year of age due to risk of causing injury, so there are adaptations for  babies (see more details further below), but a child that is too big for the babies' adaptations would require normal abdominal thrusts (according to the size of the body). Besides, abdominal thrusts should not be used when the victim's abdomen presents problems to receive them, such as pregnancy or excessive size; in these cases, chest thrusts are advised (see more details further below). In the case of choking alone, abdominal thrusts are one of the possibilities that can be tried on oneself (see more details further below). The abdominal thrusts method was discovered by doctor Henry Heimlich in 1974 . Heimlich claimed that his maneuver was better than back blows, arguing that back blows could cause the obstruction to become more deeply lodged in the victim's airway. That started a debate into the medical community, that ended up with the recommendation of alternating both techniques, but, to prevent the complications, the back blows would be performed making the patients to bend the back and supporting their chest. Although it is a well known method for choking intervention, the Heimlich Maneuver is backed by limited evidence and unclear guidelines. Use of the maneuver has saved many lives but can produce  dire consequences if not performed correctly. This includes rib fracture, perforation of the jejunum, diaphragmatic herniation, etc. Chest thrusts. When abdominal thrusts cannot be performed on the victim (because of problems as serious injuries, pregnancy or a belly size that is too much for the rescuer), chest thrusts are advised instead. Chest thrusts are performed with the rescuer embracing the chest of the choking victim from behind. Then, the rescuer closes the own dominant hand and grasps it with the other hand. This can produce several kinds of fists, but any of them can be valid if they can  be placed on the victim's chest without sinking a knuckle too painfully. Keeping the fist with both hands, the rescuer uses it to press forcefully inwards on the lower half of the chest bone (sternum). The pressure is not focused on the very endpoint (named xiphoid process) to avoid breaking it. When the victim is a woman, the zone of the pressure of the chest thrusts would be normally upper than the level of the breasts. If the first thrust does not solve the choking, it can be repeated several times. Anti-choking devices. Since 2015, several anti-choking  devices were developed and released to the market. They are based on a mechanical vacuum effect, without a power source. Most use an attached mask to make a vacuum from the patient's nose and mouth. The current models of anti-choking devices are quite similar: a direct plunger tool (LifeVac), and a vacuum syringe (backward syringe) that also keeps the tongue in place by inserting a tube in the mouth (Dechoker). Both of them have received certification, and they have been reported to be effective in real cases. Other mechanical models are in development, such as Lifewand, which creates  a vacuum by direct pressure against the patient's face. A 2020 systematic review of the effectiveness of the three devices listed here said "a more detailed review of the studies demonstrated a very low certainty of evidence for its use", and concluded that "there are many weaknesses in the available data and few unbiased trials that test the effectiveness of anti-choking suction devices resulting in insufficient evidence to support or discourage their use. Practitioners should continue to adhere to guidelines authored by local resuscitation authorities which align with ILCOR recommendations." Unconscious victims. A choking victim who becomes unconscious  must be gently caught before falling and placed lying on a surface. That surface should be firm enough (it is recommended placing a layer of something on the floor and laying the victim above). Emergency medical services must be called, if this has not already been done. While waiting for emergency services to arrive, the unconscious choking victim should receive a cardiopulmonary resuscitation (CPR) for choking victims, that is quite similar to the CPR for any other non-breathing patient. Infants less than one year old require a special adaptation for unconscious babies of that CPR (described further below). The  anti-choking CPR for unconscious adults or children, but not infants, is a cycle that alternates series of compressions with series of ventilations (rescue breaths). In that CPR: Each round of compressions applies 30 "compressions" on the lower half of the chest bone (sternum), at an approximate rhythm of nearly 2 per second. After that series, the rescuer looks for the obstructing object and, if it is visible, the rescuer makes a "try to extract" it, usually by using a finger sweeping. There are no compressions during this step, but, if the removal complicates and takes a lot of time , it may require to repeat compressions at some moments, obviously without causing hindrances to the extraction. The object can be found and removed in this step or not, but this CPR procedure must continue anyway, until the victims can breath by themselves or emergency medical services arrive. Next, the rescuer applies "a" "rescue breath", pinching the victim's nose and puffing air inside of the mouth. It is recommended, additionally, "tilting the victim's head" up and down, to reposition it trying to open an entrance for the air, and then give "an additional rescue breath". The rescue breaths would  usually fail while the object is still inside stopping them, but then the rescuer has only to continue with the next step. Anyway, they can be successful, and then the chest of the victim would rise. When a rescue breath reaches the lungs, it happens because the object has been moved to an unknown position that leaves some open space, so it can be useful making the next rescue breaths more softly to avoid moving the object to a new blocking position again, and, in case of the soft rescue breaths are not successful, increasing the strength of blowing in  the next ones. The colour of the victim's face would improve after several rescue breaths have been successful. After the rescue breaths, this resuscitation returns to the 30 initial compressions, in a cycle that repeats continually, until the victims can breathe by themselves. An anti-choking device can unblock the airway on unconscious victims, but does not necessarily remove the obstructing object from the mouth, which may need a manual removal. The victim will then require a normal cardiopulmonary resuscitation (CPR), in the manner that has been described above but only alternating the 30 compressions and the two rescue  breaths. About finger sweeping. In unconscious choking victims, the American Medical Association advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions. However, many modern protocols recommend against it. Red Cross procedures specifically direct rescuers not to perform a finger sweep unless an object can be clearly seen in the victim's mouth to prevent driving the obstruction deeper into the victim's airway. Other protocols suggest that if the patient is conscious they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should place them in  the recovery position to allow the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (inducing vomiting, for instance) by using a finger sweep technique. There are no studies that have examined the usefulness of the finger sweep technique when there is no visible object in the airway. Recommendations for the use of the finger sweep have been based on anecdotal evidence. Particular cases. Babies (under 1 year old). For babies (infants under 1 year old), the American Heart Association recommends some adapted procedures. Children  who are too big for the babies' procedures require the normal first aid techniques against choking, according to the size of their bodies. First aid for babies alternates a special cycle of back blows (five back slaps) followed by chest thrusts (five adapted chest compressions). In the "back blows maneuver", the rescuer slaps on the baby's back. It is recommended that the baby receive them being slightly leaned upside-down on an inclination. There exist several ways to achieve this: In one of the most depicted, the rescuer sits down on a seat with the baby, and supports the  baby with a forearm and its respective hand. The baby's head must be carefully held with that hand, usually by the jaw. Then the baby's body can be leaned forward upside-down along the rescuer's thighs and receive the slaps. As an easier alternative, the rescuer can sit on a bed or sofa, or even the floor, carrying the baby. Next, the rescuer should support the baby's body on the own lap, to lean the baby upside-down at the right or the left of the lap. Then the slaps would be applied on the back  of the baby. If the rescuer cannot sit down, at least it is possible to attempt the maneuver at a low height and over a soft surface. Then the rescuer would support the baby with a forearm and the hand of that side, holding the baby's head with that hand, usually by the jaw. The baby's body would be leaned upside-down in that position to receive the slaps. In the "chest thrusts maneuver", the baby's body is placed lying on a surface. Then the rescuer does the compressions on the chest bone (sternum), pressing with  only two fingers on its lower half (the nearest to the abdomen). Abdominal thrusts are not recommended in children less than one year old because they can cause liver damage. The back blows and chest thrusts are "alternated in cycles" of five back blows and five chest compressions until the object comes out of the infant's airway or until the infant becomes unconscious. When the choking is not being solved, it is mandatory that somebody calls to the emergency medical services. But the first aid has to continue until they arrive. Unconscious babies. If the infant becomes "unconscious", emergency  medical services must be called (if this has not been done yet). While they come, the American Heart Association recommends starting an anti-choking cardiopulmonary resuscitation (CPR), which must be adapted to babies. In that procedure, the baby is placed face-up on a firm and horizontal surface (the floor can be used). The baby's head must be in a straight position, looking frontally, because tilting too much a baby's head backward can close the access to the trachea. Then, it is applied a cycle of resuscitation that alternates compressions and rescue breaths, like in a normal CPR , but with some differences: The rescuer makes 30 "compressions" with only two fingers in the lower half of the chest bone (sternum), at an approximate rhythm of nearly 2 per second. At the end of the round of compressions, the rescuer looks into the mouth for the obstructing object. And, if it is visible, the rescuer makes a "try to extract it" (mainly using a finger sweep). If the removal complicates and takes too much time, it may require to repeat compressions at some moments, without hindering to the extraction. A rescuer that already knows that the choking object is  a bag (or similar) does not need to see the object before trying to extract it (because there is no risk of sinking it much deeper, and it is easy to detect by using the touch carefully). Being any object extracted or not, this CPR procedure must continue until the babies can breath by themselves or emergency medical services arrive. Next, the rescuer makes "a rescue breath", covering the baby's mouth and nose simultaneously with the own mouth, and blowing air inside. After that first rescue breath, it is recommended "tilting the baby's head" up and down (but  leaving it approximately straight again), trying to open a space for the air in that manner, and then give "an additional rescue breath." The rescue breaths usually fail while the object is still blocking, but then the rescuer has only to continue with the next step. Anyway, they can be successful, and then the chest of the baby would be seen rising. If a rescue breath reaches the baby's lungs, it is because the object has been moved to an unknown position that leaves some open space, so it can be useful making the next rescue breaths more softly  to avoid moving the object to a new blocking position again, and, in case of those soft rescue breaths are not successful, increasing the strength of blowing in the next ones. But it must be noted that the bodies of the babies are delicate, and, when the airway is not clogged, only a little strength in blowing is enough to fill their lungs. The baby's colour would improve after some successful rescue breaths. After the rescue breaths, the rescuer has to return to the 30 initial compressions, repeating the same resuscitation cycle again, continually, until the choking babies can  breath normally by themselves. Patients with abdominal problems (pregnant, obese). Some choking victims cannot receive pressure on their bellies, which requires changing the abdominal thrusts for chest thrusts, as the American Heart Association recommends for them. Those victims are, mainly: patients with serious injuries in the abdomen, pregnant women, and excessively obese people (with a size of belly that cannot be well managed). However, in the case of the obese victims, if the rescuer is capable enough to manage the size of their bodies, it is possible to apply the normal first aid against choking, with abdominal thrusts  (see details further above). When a proper pressure on the belly is not possible, chest thrusts are preferred. Chest thrusts are performed in a similar way to the abdominal thrusts, but with the fist placed on the lower half of the chest bone (sternum), rather than over the middle of the abdomen. As a reference, in women, the zone of pressure of the chest thrusts would be normally higher than the breasts. It is convenient to avoid placing the knuckles too painfully. Finally, strong inward thrusts are then applied. The rest of the first aid protocol is the same, starting  with asking the victim to cough freely, and then, if the victim cannot cough, the series of chest thrust are alternated with series of slaps on the back. Those back slaps are applied normally: bending forward the back of the victims and supporting their chest with one hand. If choking is not being solved, somebody has to call to the emergency medical services. But it is necessary to continue trying the first aid until they arrive. The victims can show a change of colour in their faces. After a while, they would lose consciousness, falling to the ground. Then  it is recommended avoiding panic and starting an anti-choking CPR for unconscious victims (see details further above). In wheelchair. If the choking victim is a disabled person in a wheelchair, the procedure is quite similar than in the case of the other victims. "The difference is in trying to apply the techniques directly, while the victim is seated on the wheelchair". "Coughing" has to be tried first, so the victim would be asked to cough freely and with strength before applying the techniques. When the victim cannot cough, it is recommended alternating series of back blows and thrusts , as in other cases. "Back blows" (back slaps) can be used after bending forward the back of the victim very much, and supporting the victim's chest with the other hand. "Abdominal and chest thrusts" can also be used. To perform the abdominal thrusts, the rescuer must get behind the wheelchair. Then the rescuer can embrace the victim's abdomen from behind and above, leaning over the top of the wheelchair's backrest. If this is too difficult, the rescuer can get down and embrace from behind the victim's abdomen and the wheelchair's backrest all together. In narrow  spaces that can not be opened, the position can be achieved by turning the victim to one side. Finally, the rescuer would grasp the own hand with the other, and place them between the chest and the belly button of the victim, and apply sudden pressures with them on that zone, in a direction of in-and-up. If the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), chest thrusts must be used instead. They are applied while the victim is in the wheelchair too, but making sudden inward pressures  on the lower half of the breast bone (sternum). If the space is too narrow and impossible to widen, the abdominal or chest thrusts can be tried by turning the victim to one side. "An alternance" of back slaps and thrusts series is used until the choking is solved, as in other victims. When choking is not being solved, it is mandatory that somebody calls to the emergency medical services. But first aid has to continue until they arrive. If a victim of choking in wheelchair becomes "unconscious", it is required an anti-chocking cardiopulmonary resuscitation (CPR), that it is  exactly the same one than in the case of non-disabled victims of choking. Anyway, it can be noted that the victim needs to be taken from the wheelchair to be placed lying face-up on an appropriated surface (not too hard or too soft, and it is possible to put a layer of something between the floor and the victim). While they arrive, the rescuer has to apply the anti-choking cardiopulmonary resuscitation for unconscious victims (see details further above). As a "preventive" measure, it is convenient to avoid placing the disabled in narrow and encased spaces at mealtimes , as more open spaces allow easier access for rescuers. Besides, placing an anti-choking device nearby is a common safety measure in environments with disabled people. Bedridden patient. Rarely, the choking victim lays in bed, but is conscious and unable to sit up (such as in disabilities or injuries)."Then the first aid would be the same, but after sitting the victim on the bed's edge". Before that, the rescuer tries that the victim coughs freely and with strength. The victim would do it better by turning to a side. When coughing is too difficult or impossible, the rescuer would  sit the victim on the bed's edge, to make coughing easier or to apply the anti-choking maneuvers (these are required if the victim cannot cough). This can be achieved grasping the victim by the legs (behind of the knees, or by the calves or ankles) and rotating them until they are out of the bed. Next, the rescuer would sit the victim up on the edge, pulling the shoulders or arms (in the forearms or wrists). Then it is possible to apply the anti-choking maneuvers from behind: series of back slaps (after bending very much the  back of the victim, and supporting the chest with one hand) and series of abdominal thrusts (sudden compressions on the part of the victim's belly that is between the chest and the belly button, in a direction of in-and-up). When the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), they must be changed for chest thrusts (sudden inward pressures on the lower half of the breast bone). When a rescuer cannot sit the victim up, it is possible to perform chest or abdominal thrusts frontally, while  the victim is laying on the bed (despite they would be less effective in that horizontal position). They are made by putting one hand on the top of the other and making with both of them strong pressures downwards on the lower half of the breast bone (the sternum), or in a downward-and-frontward direction between the chest and the belly button. If choking is not being solved, it is mandatory that somebody calls to the emergency medical services. First aid has to continue until they arrive. When the victims of choking in bed become unconscious, they need the  same anti-choking cardiopulmonary resuscitation procedure that is employed for other unconscious choking victims (see details further above). "Preventively", it is important to know that eating while laying in bed increases the risk of choking. When a disabled person is present, a common measure of prevention is placing an anti-choking device at reach. On the floor, disabled victim. In very rare cases, the choking victim would be laying on the floor but conscious, having a disability that makes impossible to sit up and to keep standing up on the feet. "Then the first aid is" "the same, but after  sitting the victim on the floor". Before that, the rescuer asks the victim to cough freely and with strength. The victim would cough better by turning to a side. If coughing is too difficult or impossible, the rescuer would sit the victim up, to make it easier or to apply anti-choking maneuvers (these are needed when the victim cannot cough). A rescuer would sit the victim up by pulling the shoulders or arms (in the forearms or wrists). Being the victim already sitting up, the rescuer can sit behind to apply the anti-choking maneuvers: back slaps (after  bending very much the back of the victim, and supporting the chest with one hand) and abdominal thrusts (sudden compressions in a direction of in-and-up, on the part of the victim's belly that is between the chest and the belly button). Some victims cannot receive abdominal thrusts properly (as the seriously injured in the belly, and the pregnant women), needing to change them for chest thrusts (sudden pressures inward on the lower half of the breast bone). In some situations it is impossible to sit the victim up, and then the rescuer can try one of  the thrusts techniques frontally on the laying victim (despite it would make them to lose effectivity). Anyway, they can be made by putting one hand on the top of the other and using them to make strong pressures downwards on the lower half of the breast bone (the sternum), or downwards-and-frontwards on the abdomen (between the chest and the belly button). In case of choking is not being solved, it is mandatory that somebody calls to the emergency medical services. Anyway, first aid has to continue until they arrive. If the victim is unconscious, it is needed the  same anti-choking cardiopulmonary resuscitation procedure that is used in other unconscious choking victims (see details further above). In the "prevention" of choking, it can be remembered the practice of placing an anti-choking device around the disabled people. Seizing victim. Seizing can occur for a multitude of reasons but is primarily common in those suffering from epilepsy. During a seizure, victims may experience strangulation or throat constriction during consciousness. The victim will not have control of their bodily functions and will need someone to create a safe area for them. One should clear a space where the victim can  lay down and remove or loosen anything that is around their neck. Then one should turn them on their side as to help them breathe and to avoid potential choking on the saliva. Self-treatment. Some first aid anti-choking techniques can be applied on oneself. One of the most realistic options when choking alone is having an approved "anti-choking device" nearby (see above). But, when none of the anti-choking devices is present, it is also possible to try the first aid techniques on oneself, mainly by hand: The most recommended manner consist in positioning the own abdomen  over the border of an object: usually a chairback, but it could work on an armchair, railing or countertop, and then "driving the abdomen upon the border", making sharp thrusts in an inwards-an-upwards direction. It is possible to "place a fist or both fists between the chosen border and the belly", to increase the pressure of the maneuver and make it easier (depending on the situation). It is also possible trying to fall on the edge, aiming to achieve more pressure in that way. Other variation of this consists in pressing one's own belly with an appropriated  object, in an inwards-and-upwards direction. Besides, "abdominal thrusts can be self-applied" only with the hands. This is achieved by making a fist, grasping it with the other hand, and placing them on the area located between the chest and the belly button. Then the body is bent forward and the hands make strong compressions pressing in an inwards-an-upwards direction. In the best of chances, it would serve as a substitute for the abdominal thrusts of another person, despite the position in oneself is not so appropriated. Anyway, in one study, the self-administered abdominal thrusts  were rated as effective as those performed by another person. When a problem makes impossible a self treatment with abdominal thrust (as serious injuries, pregnancy, or having an excessive size of the belly for oneself), it is possible to try the "self application of chest thrusts" instead, despite it would be more difficult. This would be achieved by leaning the body forward, making a fist, grasping it with the other hand, and doing strong compressions inwards with both of them on the lower half of the chest bone (sternum). It is convenient to relax the chest for a better reception . Other variation of this is the use of an appropriated object to press inwards in the same point, being equally convenient to receive the compressions when the chest is relaxed. The back blows (back slaps) maneuver is sometimes the best one for dislodging stuck objects, but it is almost impossible to apply it correctly on oneself. It is only possible to try a sort of "substitute maneuver for the back slaps", which can complement the corresponding thrusts maneuver. A similar movement to slapping on the back (despite it is not so effective) is leaning forward and hitting oneself on the  chest using the palm or heel of the hand, or the wrist. It is also possible to apply some pressure on the neck, and to shake it with the own hand (with some care, because it is a delicate area), having these movements some utility in case of the object is stuck in the neck area (which is quite probable but can be impossible to know). Making attempts to cough, when it is possible, can also clear the airway. Alternatively, multiple sources of evidence suggest that one of promising approaches for self-treatment during choking could be applying the head -down (inverse) position. To make that position, it is possible to put the hands on the floor and then place the knees on an upper seat (as on a bed, a sofa, or an armchair). Some additional movements up or down can also be tried then. Advanced treatment. There are many advanced medical treatments to relieve choking or airway obstruction, including the removal of a foreign object with the help of a laryngoscope or bronchoscope. The use of any commercial approved anti-choking device, if it is available nearby, may be a more abrupt solution, but brief. A cricothyrotomy may  be performed as an emergency procedure when the stuck object cannot be removed. This is an intervention that involves severing a little opening in the patient's neck (between the thyroid cartilage and the cricoid cartilage, until reaching the trachea) and inserting there a tube to introduce air through it, bypassing the upper airways. Usually, this procedure is only performed by someone with knowledge about it and surgical skills, when the patient is already unconscious. Epidemiology. Choking is the fourth leading cause of unintentional injury death in the United States. Many episodes go unreported because they are brief and  resolve without needing medical attention. Of the reported events, 80% occur in children younger than 15 years, and 20% occur in children older than 15 years. Choking on a foreign object resulted in 162,000 deaths (2.5 per 100,000) in 2013, compared with 140,000 deaths (2.9 per 100,000) in 1990.