The myth of swallowing your tongue: Experts warn of the danger of delaying CPR

It was during a Sevilla-Getafe match in Spain in August 2007. Around the 30th minute, 22-year-old soccer player Antonio Puerta collapsed on the pitch, just a few meters from the goalposts. Millions of viewers witnessed the scene live, either from the stadium or on their television screens. There were endless seconds of confusion, and the immediate response of his teammates, who rushed to his aid, opening his mouth and inserting their fingers, intending, it was later explained, to “keep him from swallowing his tongue.” Puerta regained consciousness a few seconds later and left the field on his own two feet, but suffered cardiac arrest in the locker room and died three days later from the after-effects of heart failure.

A more recent incident involved the Danish player Christian Eriksen, who lost consciousness during a match against Finland at Euro 2021. His teammates also moved quickly “to prevent him from swallowing his tongue,” the media later reported, although he later also received cardiopulmonary resuscitation (CPR) and defibrillation, and eventually recovered.

His case, like Puerta’s, has been used to open up a scientific reflection on how best to respond to a cardiac arrest, the misconceptions surrounding resuscitation, and its impact on public opinion: a study analyzing nearly 50 televised fainting episodes by athletes published Wednesday shows that widespread misconceptions, such as the fear that the victim might swallow their tongue, can hinder proper administration of CPR.

“the myth of tongue swallowing and its perception as a cause of cardiac arrest is widespread and often delays the initiation of effective CPR,” the researchers conclude. Their study, published in the Canadian Journal of Cardiology, analyzed interventions in 45 cases of athletes who collapsed at sporting events and were captured on camera: in 38 cases, the first attempt at resuscitation was seen on camera, and in 84% of these cases, teammates forced open the victim’s mouth to prevent tongue swallowing, rather than immediately initiating chest compressions; only six people received adequate resuscitation with chest compressions as the initial resuscitation maneuvers.

The authors cite the cases of Puerta and Eriksen because, although the outcome was different, the initial response was similar. They do not speculate on what would have happened in these specific cases if both players had immediately received the most appropriate cardiopulmonary resuscitation, with cardiac massage from the outset, but they do note a clear association in the overall case study: “Nearly 70% of athletes receiving tongue-swallowing prevention attempts died or remained in a vegetative state, whereas all 3 athletes with cardiac arrest who received chest compressions as the first CPR maneuver survived without significant anoxic brain damage [due to lack of oxygen].”

The research also highlights the role of the media in spreading misconceptions, such as this one about swallowing one’s tongue. They even document how the press routinely praises this incorrect response. It happened after the collapses suffered by Puerta and Eriksen.

Do victims really swallow their tongues?

So is there any truth to the danger of swallowing your tongue? Ignacio Fernández Lozano, president-elect of the Spanish Society of Cardiology, explains: “The tongue is a very large muscle that is anchored to the jaw. When someone loses consciousness, the tongue falls under its own weight and can obstruct the airway, but it’s not swallowed.” However, it’s not necessary to open the person’s mouth, insert your fingers and pull out their tongue. Simply perform the “head-chin maneuver.” That is, with the victim lying face up, place one hand on the forehead and the other on the chin, tilt the head back, and that will move jaw to open the airway. “This maneuver takes one second,” says Fernández Lozano, so effective resuscitation measures can begin immediately.

There’s no need to waste time trying to pull on the tongue, the cardiologist insists. It can even be “a counterproductive maneuver,” because while doing so, not only are chest compressions delayed, but the victim can also be harmed. Gemma Cuadras, a nursing assistant with the Catalan Emergency Medical System and life support instructor, agrees: “You can hurt the patient, cause a wound, cause bleeding, and further obstruct the airway.”

Both experts agree that, in the event of loss of consciousness, the most urgent thing to do is call 112 and check if the person is breathing. If they aren’t breathing, CPR must be started as soon as possible. “It’s not always clear. Sometimes breathing is abnormal, slow, labored... This is what we call agonal breathing, which occurs in some cases of cardiac arrest, where the victim gasps for air, but isn’t actually breathing. When in doubt, it’s best to start compressions,” insists Cuadras.

And a note about chest compressions: it can be helpful to do it to the rhythm of the song Macarena. A study by Hospital Clínic found that mentally following this pace increases the quality of chest compressions. However, Stayin’ Alive by the Bee Gees is also suitable. Or the SpongeBob SquarePants intro. Any of these works to set the compression rate: 120 per minute.

In Spain, Fernández Lozano recalls, survival from a cardiac arrest on the street is 9%. In the Netherlands, however, it’s 30%. “We’ve stopped there and we’re not making any progress. Spaniards don’t want to know anything about death and their health education is poor,” the cardiologist laments. He also criticizes the difficulties in accessing automatic defibrillators—“there are a tenth as many as in France”—as well as the complexity of dispelling entrenched misconceptions.

The origin of the myth

The origin of this myth about the danger of swallowing one’s tongue is unclear. In an editorial, a group of Canadian researchers suggests that it may date back to the earliest accounts of epilepsy, “which proposed that loss of consciousness could cause airway obstruction due to tongue displacement, although not actual swallowing,” they clarify. They add that this misconception has been perpetuated in popular culture thanks to films and series such as One Flew Over the Cuckoo’s Nest or Game of Thrones, where “the placement of objects in the mouth to prevent tongue swallowing during seizures is dramatized,” the authors agree.

Another hypothesis that may support this idea is that in many cases of cardiac arrest, victims may present “seizure-like activity at the onset.” This is a pattern frequently observed in sports-related cardiac arrests, they point out. Therefore, “it is understandable that this myth has carried over to the public response to cardiac arrests in athletes,” even though there are no clinical indications for such a maneuver, they assume. Furthermore, signs such as cyanosis (blue coloration of the skin) and agonal breathing can be confused with asphyxia, which may lead citizens who encounter such a condition “to prioritize inspecting the airway before initiating cardiopulmonary resuscitation.”

10 minutes of doing nothing, zero chance of survival

The big problem with all this is that these erroneous actions can delay vital interventions. “Every minute of delay in CPR decreases survival by 10% to 12%,” Cuadras summarizes. This means that, in the event of a cardiac arrest, if we wait 10 minutes without doing anything, the chances of survival are zero. “On the other hand, if we act quickly, if defibrillation is performed within the first five minutes after the arrest, the probability of survival is 70%,” he adds.

Public health education is lacking, the experts consulted agree. And the myth of swallowing one’s tongue is not the only one surrounding CPR. Canadian researchers point out that another “common misconception” is that “sudden cardiac arrest occurs exclusively in older adults with known cardiovascular diseases or abnormalities, which leads spectators in sports settings to overlook the early signs of cardiac arrest and underestimate the urgency of intervention.” Another barrier stems from the fear of causing harm or injury, such as fracturing someone’s ribs during chest compressions, delivering an inappropriate shock with an automatic defibrillator, or transmitting infections through mouth-to-mouth contact.

Regarding the fear of causing harm, Cuadras is blunt: “It’s more harmful to do nothing than to hurt a rib. If you don’t perform CPR, the victim won’t have an injury, but they probably won’t be here to tell the tale.”