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How To Treat the Choking Conscious Infant

By Charles D. Bortle, EdD, Director of Clinical Simulation, Office of Academic Affairs, Einstein Medical Center

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Patient Education

Choking in an infant is usually caused by inhaling a small object the baby has placed in their mouth, such as food, a toy, or other small object (eg, a button, coin, or balloon). If the airway obstruction is severe, then back blows followed by chest thrusts are administered to dislodge the object.

Indications

  • Choking due to severe upper airway obstruction due to a foreign object.

A choking infant with severe airway obstruction, as indicated by the following:

  • Cyanosis

  • Retractions

  • Inability to cry or make much sound

  • Weak, ineffective coughing

  • Stridor

Do not interfere if the infant can cry and make significant sounds, cough effectively, or breathe adequately, as they do not have severe airway obstruction. Furthermore, strong coughs and cries can help push the object out of the airway.

Contraindications

Absolute contraindications:

  • Do not do back blows or chest thrusts if the infant stops breathing for reasons other than an obstructed airway such as asthma, infection, swelling, or a blow to the head.

Relative contraindications:

  • None

Complications

  • Rib injury or fracture

  • Internal organ injury

Equipment

  • None

Additional considerations

  • This rapid first aid procedure is done immediately wherever the infant is choking.

Positioning

  • For back blows, hold the infant face down along your forearm using the thigh or lap for support. Hold the infant’s chest in your hand and the jaw with your fingers. Point the infant’s head downward and lower than the body.

  • For chest thrusts, hold the infant facing upward and with the head down, along your forearm, using the thigh or lap for support. Hold the infant’s head in your hand.

Back blows—infant.

Back blows are delivered with the infant in a head-down position to dislodge foreign bodies from the tracheobronchial tube. (Adapted from Standards and Guidelines for Cardiopulmonary Resuscitation [CPR] and Emergency Cardiac Care [ECC], in the Journal of the American Medical Association 25:2956 and 2959, June 6, 1986. Copyright 1986, American Medical Association.)

Chest thrusts—infant.

Chest thrusts are delivered on the lower half of the sternum, just below the nipple level.

Relevant anatomy

  • The vocal cords in the larynx protect the airway. Food and foreign objects that are aspirated and cause upper airway obstruction are usually stopped at this level.

  • In infants and children, the cricoid cartilage is the most narrow part of the upper airway. Objects can become trapped between the vocal cords and the cricoid ring, resulting in an obstruction that is particularly difficult to clear.

Step-by-step description of procedures and key teaching points

  • Determine if there is severe airway obstruction which may endanger the infant’s life. Look for signs of severe airway obstruction such as the inability to cry audibly, cough effectively, or breathe adequately (eg, stridor, retractions, cyanosis).

  • If the infant has a strong cry or is coughing hard do not perform these procedures. If you have determined that the infant has severe airway obstruction, proceed with the following procedures.

  • Tell someone to call 911 while you begin first aid. If you are alone, shout for help and begin first aid.

  • Hold the infant’s face down along your forearm using the thigh or lap for support. Hold the infant’s chest in your hand and open the jaw by pulling the mandible with your fingers. Point the infant’s head downward and lower than the body.

  • Give up to 5 quick, forceful back blows between the infant’s shoulder blades using the palm of your free hand.

  • Check the mouth to see whether the aspirated foreign body is visible; if it can be easily removed, remove it.

  • If the object does not come out of the airway after 5 back blows, turn the infant face-up.

  • Hold the infant face-up along your forearm using the thigh or lap for support. Hold the head in your hand with the head lower than the torso.

  • Place 2 fingers on the middle of the infant’s sternum just below the nipples. Avoid the lower ribs or the tip of the sternum.

  • Give up to 5 quick thrusts, compressing the chest about 1/3 to ½ the depth of the chest—usually about 1.5 to 4 cm (0.5 to 1.5 inches) for each thrust.

  • Continue to deliver 5 back blows followed by 5 chest thrusts until the object is dislodged or the infant becomes unconscious.

  • Do not try to grasp and pull out the object if the infant is conscious.

  • If the infant becomes unresponsive (unconscious), shout for help and begin infant CPR. If you are alone, after 1 minute of CPR call 911.

  • If the infant is unconscious, if you can see the object blocking the airway, try to remove it with a finger. Try to remove the object only if you can see it.

Aftercare

  • The infant should be examined by a physician as soon as possible, even after successful removal of the airway obstruction and resumption of normal breathing.

Warnings and common errors

  • Do not do back blows or chest thrusts if the choking infant can cry audibly, cough forcefully, or breathe adequately.

  • Do not do back blows or chest thrusts if the infant stops breathing for reasons other than an obstructed airway (eg, asthma, infection, angioedema, head injury). Do give CPR in these cases.

  • Do not perform blind finger sweeps on infants.

  • Do not perform abdominal thrusts (Heimlich maneuver) on infants.

Tips and tricks

  • It is important to use gravity as an ally. Keep the infant's head lower than its torso during the procedure.

References

  • American Heart Association: Basic Life Support (BLS) Provider Manual. Dallas, American Heart Association, 2016.

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