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Gastric Perforation after Heimlich Maneuver

      To the Editor:
      The Heimlich maneuver is life-saving in a patient choked by a foreign body.
      • Heimlich H.J.
      A life saving maneuver to prevent food-choking.
      However, rare complications have been reported following this maneuver, even when it was performed properly. Herein, we present a case of gastric perforation following a forceful Heimlich maneuver in a patient with nasopharyngeal cancer.
      A 59-year-old woman suffered from airway obstruction while she was eating breakfast, with immediate loss of consciousness. She had a medical history of nasopharyngeal cancer and had undergone radiotherapy. She had subsequent impaired swallowing function and was easily choked. Upon arrival, an emergency medical technician (EMT) attempted the Heimlich maneuver several times in order to relieve the airway obstruction. The attempt failed, however, and the patient suffered sudden cardiac arrest. The EMT then started cardiopulmonary resuscitation immediately, and the patient was transported to our Emergency Department. There, food debris that obstructed the airway of the patient was removed by instruments. After endotracheal intubation and further resuscitation, return of spontaneous circulation was noted with recovery of consciousness. The patient's chest radiography then showed massive subphrenic free air (Figure). Thus, an exploratory laparotomy was performed due to suspicion of hollow organ perforation. Several tears of the gastric wall were identified and repaired. The postoperative course was favorable, and the patient was discharged uneventfully 10 days later.
      Figure thumbnail gr1
      FigureChest radiography shows free air under the diaphragm.

      Discussion

      The Heimlich maneuver was first described in 1974, and thereafter, this simple procedure has saved many lives by relieving airway obstruction.
      • Heimlich H.J.
      A life saving maneuver to prevent food-choking.
      However, complications such as rib fracture, diaphragm rupture, pneumomediastinum, acute thrombosis of abdominal aortic aneurysm, mesenteric laceration, and traumatic injury of the gastrointestinal tract also have been reported after the Heimlich maneuver.
      • Haynes D.E.
      • Haynes B.E.
      • Yong Y.V.
      Esophageal rupture complicating Heimlich maneuver.
      • Chapman J.H.
      • Menapace F.J.
      • Howell R.R.
      Rupture aortic valve cusp: a complication of the Heimlich maneuver.
      • Kirshner R.L.
      • Green R.M.
      Acute thrombosis of abdominal aortic aneurysm subsequent to Heimlich maneuver: a case report.
      • Agla G.A.
      • Hurst D.J.
      Pneumoperitoneum following the Heimlich maneuver.
      • Valero V.
      Mesenteric laceration complicating a Heimlich maneuver.
      • Ujjin V.
      • Ratanasit S.
      • Nagendran T.
      Diaphragmatic hernia as a complication of the Heimlich maneuver.
      Gastric perforation is another rare but life-threatening complication of this maneuver.
      • Fearing N.M.
      • Harrison P.B.
      Complications of the Heimlich maneuver: case report and literature review.
      In our case, the gastric perforation was possibly caused by the multiple abdominal thrusts attempted. Physicians should be aware of this rare complication of the Heimlich maneuver in order to have an early diagnosis and prompt management.

      References

        • Heimlich H.J.
        A life saving maneuver to prevent food-choking.
        JAMA. 1975; 234: 398-401
        • Haynes D.E.
        • Haynes B.E.
        • Yong Y.V.
        Esophageal rupture complicating Heimlich maneuver.
        Am J Emerg Med. 1984; 2: 507-509
        • Chapman J.H.
        • Menapace F.J.
        • Howell R.R.
        Rupture aortic valve cusp: a complication of the Heimlich maneuver.
        Ann Emerg Med. 1983; 12: 446-448
        • Kirshner R.L.
        • Green R.M.
        Acute thrombosis of abdominal aortic aneurysm subsequent to Heimlich maneuver: a case report.
        J Vasc Surg. 1985; 2: 594-596
        • Agla G.A.
        • Hurst D.J.
        Pneumoperitoneum following the Heimlich maneuver.
        JACEP. 1979; 8: 473-475
        • Valero V.
        Mesenteric laceration complicating a Heimlich maneuver.
        Ann Emerg Med. 1986; 15: 105-106
        • Ujjin V.
        • Ratanasit S.
        • Nagendran T.
        Diaphragmatic hernia as a complication of the Heimlich maneuver.
        Int Surg. 1984; 69: 175-176
        • Fearing N.M.
        • Harrison P.B.
        Complications of the Heimlich maneuver: case report and literature review.
        J Trauma. 2002; 53: 978-979