Café coronary syndrome – case report and medicolegal implications

Introduction

The term “café coronary syndrome” was introduced by Haugen in 1963 to describe a sudden collapse of healthy people during meals in the absence of any sign of asphyxia, respiratory distress, or neurological symptoms. ¹ Typically, the patient swallows a food bolus (usually meat) larger than the oesophagus can accept. The food bolus lodges in the hypopharynx or trachea, causing an acute obstruction of the airways by food (“choking”), leading to the syndrome.

Asphyxia is a generic term to describe conditions in which there is a lack of blood oxygenation due to any failure or disturbance of the respiratory process. Choking is a form of asphyxia in which the occlusion, partial or total, of the airways by foreign bodies leads to respiratory blockage and, potentially, death.

In café coronary syndrome, the most supported theory is that choking causes the airways’ total obstruction, leading to recurrent vagal nerve stimulation with subsequent vagal activation and reflex heart inhibition, resulting in cardiac arrest. ²

Due to the absence of clear choking symptoms, café coronary syndrome is often confused with a myocardial infarction. Misdiagnosis leads to wrong management and potentially fatal outcome. Thus, medico-legal litigation may arise.

This paper reports a case of café coronary syndrome and a discussion about the possible medico-legal implications in fatal cases.

Case report

An inmate, a 75-year-old white male with a medical history of hypertensive atherosclerotic cardiovascular disease, suddenly collapsed while sitting in his cell. According to his cellmate, he was drinking a glass of water when he suddenly collapsed without any symptoms. A plate with some food was present in the cell, and the cellmate suspected a possible choking. The jail’s primary care provider and the nurse were immediately notified. The cellmate attempted an unsuccessful Heimlich manoeuvre. When the physician arrived a couple of minutes later, he found the subject unresponsive on the floor. Based on the history provided by the cellmate, he inspected the oral cavity searching for potential foreign bodies, that were not identified. However, he tried again using the Heimlich manoeuvre but it was still not effective. Thus, the possibility of choking was excluded, and myocardial infarction was suspected. The healthcare professionals attempted cardiopulmonary resuscitation, but the subject died quickly. The death certificate signed by the jail’s physician reported cardiac arrest due to myocardial infarction as the possible cause of death.

The legal authority requested an autopsy. No evidence of trauma was present at the external examination of the body. Inspection of the oral cavity disclosed moist mucosa and poor dentition (Figure 1).

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Figure 1.

Poor dentition observed at the oral cavity inspection.

No foreign bodies were visible in the retropharyngeal space. The heart weighed 661 g and showed an interventricular septum hypertrophy up to 1.8 cm. Multiple, ill-defined myocardial sclerotic spots were also observed. There was moderate to severe atherosclerosis of the coronary arteries, aorta (Figure 2), and circle of Willis.

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Figure 2.

Severe diffuse aortic atherosclerosis consistent with a long history of hypertensive atherosclerotic cardiovascular disease.

No evidence of acute coronary thrombosis, myocardial infarction or stroke was observed at the gross and microscopic examination.

The neck dissection showed no evidence of soft tissue injuries. Upon eviscerating the tongue, pharynx, larynx, and proximal trachea, a large tan-grey, friable material was observed in the larynx lumen. The larynx was dissected, revealing an 11.0 × 6.0 × 4.0 cm food bolus, consistent with un-chewed meat, stuck in the larynx lumen and extending distally up to the second tracheal ring (Figure 3).

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Figure 3.

Foreign body (meat bolus) stuck in the larynx.

The food bolus caused a total obstruction of the upper airways. Attempts to dislodge the food by forceps resulted in a diffuse fragmentation of the soft, friable food material (Figure 4).

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Figure 4.

Friable food material.

Toxicological analyses were negative for alcohol and illicit drugs.

Death was due to choking, and due to the absence of any reported asphyxia symptoms, it was consistent with café coronary syndrome. The final medico-legal diagnosis changed the original one erroneously supposed by the jail’s healthcare provider.

After signing out the report, due to discrepancies in the final cause of death, the legal authority asked the forensic pathologist about the potential professional negligence of the healthcare providers who took care of the subject, and if any potential manoeuvre or procedure could have saved the deceased’s life.

Discussion

Most fatal café coronary syndrome cases are unwitnessed, but even deaths that occur in public places are often erroneously attributed to myocardial infarction. ³ People who suffer from this syndrome will not necessarily have a history of cardiovascular disease or risk factors. However, the classic patient is an elderly man with poor dentition and history of neurological or psychiatric disorders. ⁴ , ⁵ Nevertheless, the syndrome has also been described in children. ³

A quick differential diagnosis between choking and myocardial infarction is mandatory to attempt adequate, potentially life-saving manoeuvres.

The classic choking symptoms include acute respiratory distress, cough, speech problems, cyanosis, and collapse. The death in choking is usually sudden or quick unless the foreign body obstructing the airways is removed.

Conversely, the typical myocardial infarction presentation includes retrosternal chest pain, often radiating to the left arm and/or the neck and jaw, associated with neurovegetative signs (nausea, vomit, pallor, sweating, etc.). In myocardial infarction, usually death occurs after a short or long interval from the beginning of the symptoms.

However, in café coronary syndrome, the choking symptoms are absent, which explains why this condition is often misdiagnosed as a myocardial infarction, especially in patients with a history of cardiovascular disease. In these cases, recognising choking allows attempting several manoeuvres and procedures to dislodge or remove the foreign body and restore the subject’s airway.

To better discuss the potential medico-legal implication of a misdiagnosed café coronary syndrome, it is necessary to describe the basic manoeuvres and procedures that may be helpful in restoring the patient’s airway patency.

The Heimlich manoeuvre (“abdominal thrusts”) is well known among the general public due to its application in out-of-hospital basic life support. The Heimlich manoeuvre is the indicated first-line approach for conscious, non-pregnant adults with supra-laryngeal airway obstructions and can be performed by bystanders with minimal medical training. This technique causes a sudden increase in intra-abdominal pressure, ideally leading to the forceful dislodgment of the impacted object. While studies have validated that the Heimlich manoeuvre causes an increase in intra-abdominal pressure, the efficacy of this mechanism for expelling airway obstructions has not been quantified.

The technique proceeds as follows: ⁶

Standing behind the choking victim, place the clenched fist of the non-dominant hand just above the umbilicus and cover with the palm of the dominant hand.

If the Heimlich manoeuvre fails, direct laryngoscopy may reveal the foreign body and its position in the upper airways. An attempt of foreign body removal can be done during laryngoscopy.

Intubation is another potential alternative, but it is not feasible in all cases (including the case described in this paper). Intubation may push the foreign body distally. While small foreign bodies can be moved into the right main bronchus, allowing a certain degree of oxygenation through the left one, large foreign bodies will cause a total obstruction of the lower airways, worsening the conditions. ⁷

If abdominal thrusts and chest compressions are unsuccessful, and laryngoscopy and intubation are not feasible, qualified experienced healthcare professionals may elect to proceed with a cricothyrotomy.

Cricothyrotomy involves placing a tube through an incision in the cricothyroid membrane to establish an airway. In addition to foreign body obstruction, a cricothyrotomy is also indicated for oromaxillofacial or C-spine trauma, oral haemorrhage, copious emesis, or in patients with anatomy which precludes intubation. The scalpel-finger-bougie technique for performing a cricothyrotomy is as follows: ⁸

Locate the cricoid membrane in the midline 2 cm below the inferior border of the thyroid cartilage, immediately above the superior border of the cricoid cartilage, and laterally bordered by the cricothyroideus muscles.

If the cricothyrotomy fails, tracheotomy is an invasive option to circumvent an upper airway obstruction. Although there are various anecdotal benefits of tracheotomy, the only proven positive effects are increased patient comfort and decreased intensive care unit stay. Additionally, it may be a superior option for patients likely to need lower airway suctioning. While an elective tracheostomy is usually used in the management of patients requiring prolonged mechanical ventilation, it is not indicated in emergency situations since it is time consuming and the loss of airways does not give much time to the patient. The American Society of Anesthesiology defines “emergency airway” as a situation in which facemask ventilation or tracheal intubation of the upper airway is not adequate or unsuccessful. Emergency percutaneous tracheostomy should be performed by adequately trained operators in appropriate settings in emergency situations. Several techniques have been described. One of the standard approaches for emergency percutaneous tracheotomy is as follows: ⁹

Extend the patient’s neck over a shoulder roll.

A summary of the suggested action path in cases of suspect choking is shown in Figure 5.

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Figure 5.

Suggested action path in case of suspect choking.

In general, medical malpractice due to misdiagnosis arises when the patient (or their representative) proves that there was a doctor–patient relationship, that the doctor failed to accomplish with the standard of care in diagnosing the patient’s condition, and that the doctor’s failure to diagnose or misdiagnosis actually and proximately caused an actual injury. Beyond the frequent legislative updates, medical malpractice in Italy is generally based on three principles: ¹⁰

Negligence: a conduct characterised by neglect or superficiality or even inattention and distraction during the care of a patient.

In the presented case, the forensic pathologist was also required to discuss if any emergency manoeuvre or procedures would have avoided the fatal outcome.

In the evaluation of potential medical malpractice, it was mandatory to consider multiple aspects.

First, the setting. The event happened in a prison setting, which does not include a fully equipped medical area. Moreover, incarcerated patients often do not have access to high-quality emergency care available to patients in the community at emergency departments. ¹¹

Second, the location and size of the food impaction. The autopsy showed evidence of a large piece of meat stuck in the larynx, extending from the subepiglottic area to the second tracheal ring. There was no extension over the epiglottis, and thus, no visible foreign body was visible at the oral cavity inspection. The food bolus caused a total obstruction of the airways.

Third, Heimlich manoeuvre. According to the investigation, when first responders arrived on the scene, they tried the Heimlich manoeuvre that was unsuccessful. Even in the absence of choking symptoms, the Heimlich manoeuvre was attempted both from the cellmate and the first responders. However, this manoeuvre is not always effective in displacing the foreign body. ¹²

Fourth, laryngoscopy and intubation. In the present case, laryngoscopy was not available in the jail, and a potential intubation would have worsened the condition, pushing the large food bolus distally.

Fifth, other potential life-saving procedures. Regarding cricothyrotomy, while there are no absolute contraindications to this technique and it can be attempted outside the hospital setting, it will be ineffective if the obstruction is located below the level of the cricoid membrane. Thus, in this case, due to the location of the food impaction, cricothyrotomy would not have helped restore the patient’s airways.

While emergent tracheostomy produces a stable airway, it is not generally performed and recommended in pre-hospital services due to its many risks. Due to the proximity of the innominate artery, left carotid artery, apical pleura, and mediastinal structures, this procedure has a significant risk rendering it better suited for the controlled setting of the operating room. Complications include haemorrhage, pneumothorax, pneumomediastinum in addition to tracheal, oesophageal, or recurrent laryngeal nerve injury. ¹³ Multiple factors must be considered when attempting an emergent tracheostomy, including the setting, choice of technique to manage the emergency airway, patient anatomy, user experience, and available devices. ¹⁴ In the present case, the prison setting, the absence of emergency medicine physicians, the unavailability of adequate devices, and the absence of clear evidence of respiratory distress prevented emergency tracheostomy from being performed safely.

As an essential medical principle, no conscientious physician should perform any procedure with which they are not familiar. Additional medico-legal problems may arise from erroneously performed techniques, even if done in an attempt to save the patient.

According to all the available evidence mentioned above, no medical malpractice was found. Moreover, considering all the aspects mentioned above, even invasive emergency procedures would not have saved the patient.

In fatal café coronary syndrome cases, a high suspicion is required to diagnose choking instead of a cardiac event. Advanced age, poor dentition, and a long history of cardiovascular disease are red flags for this syndrome that should be in the differential diagnosis of cases of collapse during meals.

On the one hand, impulsively attributing the death to a cardiovascular event can result in a loss of the patient’s chance of survival because potential life-saving manoeuvres and procedures should not be delayed.

On the other hand, when investigating potential medical malpractice it is critical to evaluate the event from the first responders’ point of view. In cases like the presented one, forensic pathologists should at least consider: evidence of any symptoms suggestive of choking; if myocardial infarction was a potential differential diagnosis; if the first responders tried any life-saving manoeuvres or procedures to restore the patient vital signs; if there were other possible procedures and if they would have changed the course of the event.

It is essential to keep in mind that in café coronary syndrome, the diagnosis can be challenging. Due to the absence of apparent choking symptoms and the frequent history of cardiovascular disease, a wrong diagnosis is unfortunately common, and myocardial infarction is often the hypothesised cause of death. However, an incorrect diagnosis does not necessarily indicate medical malpractice. The first responders who manage the patient often see no clinical signs of a potential choking. Therefore, it is exceptionally difficult to include this cause of death in the differential diagnosis, especially considering the emergency situation where the available time is very limited. These emergencies are unlikely to be fixed in non-medical settings. Thus, in the present case even a prompt diagnosis would not have changed the outcome.

Moreover, if the first responders demonstrate that they did everything they can to restore the patient’s airways, using the available resources and time, no medical malpractice can be supported. In these situations, the following Latin legal maxim is usually applied in Italian courts: “ad impossibilia nemo tenetur”, meaning that nobody is held to the impossible.

The present case is an example of a typical witnessed, fatal café coronary syndrome. The absence of choking symptoms often leads to misdiagnosis, but the investigations and the autopsy examination may give essential information to determine if the healthcare personnel’s actions were negligent or not. Even in the presence of wrong diagnosis, it is mandatory to highlight if the necessary omitted procedures, if performed, could have saved the patient’s life.