Doctors speak of so-called bolus death when a foreign body that is too large, usually a piece of food, is stuck between the larynx and esophagus and triggers a reflex cardiac arrest by irritating the upper laryngeal nerve. The term “Bolustod” (bolus death) comes from the Greek word “bolos” – back “lump”.
What is a bolus death?
According to growtheology, bolus death is not death from asphyxiation. In contrast to aspirating a foreign body, whereby food or objects get into the airways, in bolus death the foreign body is swallowed into the pharynx (gullet) or the esophagus (esophagus). If the swallowed chunk then gets stuck in the throat or in the entrance area of the esophagus – the narrow cricoid cartilage – and presses on the nerve plexus there, a reflex cardiac arrest can occur.
Because parasympathetic nerves run there, especially the Xth cerebral nerve, called the vagus nerve. The vagus nerve is part of the parasympathetic nerve that is responsible for slowing the heartbeat. And if the vagus nerve is extremely irritated by a foreign body, the heart rate may be slowed down to such an extent that cardiac arrest and so-called bolus death can occur.
If the foreign body is stuck in the middle or lower esophagus, it is also an emergency whether or not there are any noticeable symptoms. A foreign body stuck in the esophagus can perforate the esophagus.
Be food insufficient chewed pieces can be swallowed intentionally or accidentally, which are too large to clear the way through the larynx (hypopharynx) into the esophagus (esophagus back down without hindrance). The following pathomechanism can then occur: the stuck foreign body irritates the larynx wall and an excessive vagal reaction leads to cardiac arrest.
The superior laryngeal nerve is irritated in the neck, a branch of the vagus nerve, the Xth cranial nerve of the parasympathetic nerve. As a result, the heart and circulation are throttled, reflex bradycardia and, above all, cardiovascular arrest occur. So the victim does not choke on the food. The reflex that leads to sudden cardiovascular arrest is caused by the foreign body stuck in the throat and pressing on the larynx nerve plexus.
The nerve plexus in the larynx becomes so irritated that the heart rate is drastically slowed and cardiac arrest occurs. In healthy adults, swallowing chunks of food that are too large is rare, but it does happen, for example with a piece of meat. In the vernacular, bolus death is therefore also known as bockwurst death, or swallowing death.
Symptoms, ailments & signs
In contrast to the impending bolus death, where the patient usually collapses silently, the patient gasps for air more noisily and shows signs of cyanosis (turns blue due to the lack of oxygen in the blood).
If someone sits at the table while eating, suddenly suffers from shortness of breath and grabs their neck, a foreign body is often the cause. If a chunk of food (or a set of teeth) has got stuck in the throat, there is sudden panic, there is usually no coughing attack, at most, coughing with immediate shortness of breath.
Diagnosis & course
Since the person concerned becomes unconscious within a few minutes in the event of an impending bolus death, the diagnosis of the emergency doctor will initially be based on the external anamnesis of witnesses. As with a complete obstruction of the airway, rapid action is required; it is a life-threatening emergency situation.
If time permits, the foreign body can be removed under sight (laryngoscope) with special forceps. The last remedy of choice would be the cricothyrotomy (opening of the airways at the level of the larynx, popularly incorrectly referred to as a tracheal incision). Since the heart can stop beating within seconds if a bolus death is imminent, it must first and foremost be resuscitated quickly.
Several hours after the foreign body has been removed (for example through a “Heimlich maneuver”), the patient may still suffer from dysphagia (swallowing disorders). It must be checked whether there are internal injuries or whether there are any remains of the foreign body in the larynx or esophagus. This is done by inspecting the mouth and throat and using laryngoscopy (reflection of the larynx) or ÖGD (esophagogastroduodenoscopy).
The complication of bolus death is death of the patient. In many cases death cannot be prevented if the nerve is already too depressed and cardiac arrest occurs. Should bolus death occur, extremely quick action is required to save the patient’s life.
Most of the time, the affected person faints after just a few minutes and is no longer accessible. If the emergency doctor arrives quickly enough, the foreign body can be removed from the patient with the help of special pliers. Usually, however, an incision is made in the trachea. The affected person is also reanimated so that the heart beats again.
Most of the time, there are no further complications after bolus death treatment. A few hours after the operation, the patient may experience disturbances and pain when swallowing, but these will go away on their own. If the foreign body is swallowed, it can injure the esophagus or the larynx.
Pieces of the foreign body can also remain there. These can then be surgically removed. There are no further complications here. In the event of a bolus death, quick action is necessary. Witnesses can remove the foreign body from the patient by giving him strong blows between the shoulder blades. The so-called Heimlich maneuver can also be used.
When should you go to the doctor?
In the event of impending bolus death, the life of the person concerned can only be saved by acting extremely quickly. The question of whether and when to see a doctor does not even arise here. The emergency doctor must be notified immediately if the first signs of an impending bolus death appear. If the patient is taken to the hospital, he usually dies on the way there.
Before the emergency doctor arrives, first aid measures must be taken. These are often crucial for the patient’s survival. If the person concerned is conscious, he should try to remove the foreign body by grasping the throat. If the foreign body cannot be reached, another person must try to loosen it with a few powerful blows between the shoulder blades.
Then it can often be coughed up. An attempt can also be made to loosen the foreign body by increasing the pressure inside the abdominal cavity. The so-called Heimlich maneuver is particularly effective, but it is usually only mastered by trained first aiders. If the incident occurs in a larger group or in a public place, people who are familiar with this first aid technique should be sought specifically.
Treatment & 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, a grip in the throat can sometimes be enough. Otherwise, the first thing you should try is to loosen the foreign body with a few powerful blows between the shoulder blades – preferably with the ball of your hand.
If this remains unsuccessful after five strokes, the “Heimlich maneuver” can be used, up to five strong compressions in the area of the epigastrium. The first aider stands behind the patient and puts his own arms around the patient’s upper abdomen area, just below the costal arch. One hand is best clenched into a fist and the other hand grips the fist.
Then a few times forcefully and jerkily into the upper abdomen of the patient, inward and a little upward, towards the spine. The desired effect of this sudden intra-abdominal overpressure (increase in pressure within the abdominal cavity) is that the foreign body is pushed out or is coughed out. This maneuver can also be used with the patient lying down.
The fact that this can also lead to internal injuries is a risk that is gladly accepted when life is in danger – so inexperienced first aiders in particular should not be afraid to use force. If neither the blow between the shoulder blades nor the Heimlich maneuver do anything, the emergency doctor can try to remove the stuck object with special pliers.
If this is not possible either, a tracheotomy may be necessary. In the event of cardiovascular arrest, resuscitation must be carried out (chest compressions in the middle of the chest, with a frequency of 100 per minute and a pressure depth of five to six centimeters, chest compressions: ventilation at a ratio of 30: 2).
Outlook & forecast
The prospect and prognosis of bolus death depend on the speed at which the person concerned is being helped. It concerns the possible first aid measures and something that has to be done 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 affected person will die. Accordingly, it can be observed that a transport to hospital by an emergency doctor is associated with a considerable risk of death, since the few minutes of transport in the event of a cardiac arrest are sufficient to cause brain death in the person concerned.
On the other hand, if action is taken quickly on the spot, death can be averted in many cases. The type of first aid measures is decisive here: an attempt should first be made to remove the foreign body from the person concerned (if he is still conscious), then chest compressions with ventilation can be performed later.
Once the foreign body has been removed, the patient can often be resuscitated (provided that the pressure on the vagus nerve was not too great) and he survives the incident without permanent damage.
In the course of the initial treatment, pain in the larynx and difficulty swallowing can then occur. But these pass within hours or days.
The best prevention is to eat relaxed and thoroughly chew all food. Be careful with drinks with larger ice cubes: best enjoyed with a straw. Small children like to put objects in their mouths and run the risk of accidentally swallowing them. Age-appropriate toys with no small parts that the little ones can swallow help prevent this.
Patients with disorders associated with swallowing disorders (dysphagia), such as Parkinson’s disease, MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis) or dementia, should be carefully observed and supported while eating.
In the case of a bolus death, follow-up care is based on the course of the disease. If the bolus death can be averted by immediate rescue measures, the shock associated with it must first and foremost be overcome. Any trauma is overcome in the context 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 died from a bolus should check the household for small items and install safety mechanisms on drawers and cupboards. Check-ups can help rule out bleeding in the throat and other complications.
In the event of a fatal bolus death, the relatives usually also need therapeutic support. It often takes years to process the trauma. Aftercare may include tapering off any antidepressants. Those affected should also consult their family doctor and therapist on a regular basis.
Even years after a trauma, psychological or psychosomatic complaints can arise. These must be recognized and treated before the physical or mental condition deteriorates further. There is therefore no uniform follow-up care for a bolus death. Follow-up care is based on the effects of bolus death and the course of any therapies and medication measures.
You can do that yourself
In bolus death, a large foreign body in the throat area causes reflex cardiac arrest. The first step must therefore always be to remove the foreign body. If the patient is conscious, he should try to do this himself by grasping the throat. Affected people often lose consciousness very quickly when they are threatened with bolus death. 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 doctor must be called immediately and an acute danger to life for the patient must be reported. Since those affected do not suffocate after bolus death and as a result do not gasp or panic for breath, but often collapse silently, the first signs are often underestimated and considered to be simple circulatory weakness. As a result, valuable time is lost, which can result in the death of the person concerned. If a person collapses while eating, an acute emergency should therefore always be assumed.
Before the emergency doctor arrives, first aid measures must be taken. In doing so, the patient should first be hit hard several times against the shoulder blades with the ball of the hand. If this is not enough to remove the foreign body, the Heimlich maneuver (upper abdominal compression) should be used.
The best prevention against bolus death is thorough chewing of the food and adequate attachment of third teeth, which are not infrequently responsible for reflex cardiac arrest.