(See also Overview of Respiratory Arrest Overview of Respiratory Arrest Respiratory arrest and cardiac arrest are distinct, but inevitably if untreated, one leads to the other. (See also Respiratory Failure, Dyspnea, and Hypoxia.) Interruption of pulmonary gas exchange... read more and Airway Establishment and Control Airway Establishment and Control Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more .)
Indications
Choking due to severe upper airway obstruction due to a foreign object (signaled by inability to speak, cough, or breathe adequately)
The Heimlich and other maneuvers should be used only when the airway obstruction is severe and life is endangered. If the choking person can speak, cough forcefully, or breathe adequately, no intervention is required.
Contraindications
Absolute contraindications
Age < 1 year is a contraindication to the Heimlich maneuver (see How to Treat the Choking Conscious Infant How To Treat the Choking Conscious Infant Choking in an infant is usually caused by a small object the baby has placed in its mouth (eg, food, toy, button, coin, or balloon). If the airway obstruction is severe, then back blows followed... read more ).
Relative contraindications
Children < 20 kg (45 lb; typically < 5 years) should receive only moderate pressure thrusts and back blows.
Obese patients and women in late pregnancy should receive chest thrusts instead of abdominal thrusts.
Complications
Rib injury or fracture
Internal organ injury
Additional Considerations
These rapid first aid procedures are done immediately wherever the person is choking.
Use of significant, abrupt force is appropriate for these maneuvers. However, clinical judgment is needed to avoid excessive forces that can cause injury.
The Heimlich maneuver is well known and widely used. However, chest thrusts and back blows may produce higher airway pressures. More than one maneuver may be used in succession if the initial maneuver fails to remove the obstructing object.
Positioning
In general, the rescuer stands behind the choking person or kneels behind a child.
Relevant Anatomy
The epiglottis usually protects the airway from aspiration of foreign objects (eg, food).
Aspirated objects may be above or below the vocal cords.
Step-by-Step Description of Procedure
Determine if there is severe airway obstruction
Look for signs such as inability to speak, cough, or breathe adequately.
Look for hands clutching the throat, which is the Universal Distress Signal of severe airway obstruction.
Ask: “Are you choking?”
If the person can speak and breathe, encourage them to cough but do not initiate airway clearance maneuvers; instead arrange medical evaluation.
If the choking person nods yes or cannot speak, cough, or breathe adequately, that suggests severe airway obstruction and the need for airway clearance maneuvers.
Treat the choking conscious adult or child
Stand directly behind the choking adult or kneel behind a child.
Begin with abdominal thrusts for people who are not pregnant or obese; do chest thrusts for obese patients and women in late pregnancy.
Alternate between sets of abdominal thrusts (Heimlich maneuver), chest thrusts, and back blows as needed to relieve the obstruction.
Continue until obstruction is removed or advanced airway management is available.
If the person loses consciousness, start cardiopulmonary resuscitation Cardiopulmonary Resuscitation (CPR) in Adults Cardiopulmonary resuscitation (CPR) is an organized, sequential response to cardiac arrest, including Recognition of absent breathing and circulation Basic life support with chest compressions... read more (CPR). After each set of chest compressions, look inside the patient's mouth before giving rescue breaths and remove any visible obstruction that can be reached. Do not do blind finger sweeps.
Abdominal thrusts (Heimlich maneuver):
Encircle the patient’s midsection with your arms.
Clench one fist and place it midway between the umbilicus and xiphoid.
Grab the fist with the other hand (see figure Abdominal thrusts with victim standing or sitting Abdominal thrusts with victim standing or sitting (conscious) The Heimlich maneuver (abdominal thrusts) is a rapid first-aid procedure to treat choking due to upper airway obstruction by a foreign object, typically food or a toy. Chest thrusts and back... read more ).
Deliver a firm inward and upward thrust by pulling with both arms sharply backward and upward.
Rapidly repeat the thrust 6 to 10 times as needed.
Abdominal thrusts with victim standing or sitting (conscious)
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Chest thrusts:
Encircle the patient’s midsection with your arms.
Clench one fist and place it on the lower half of the sternum.
Grab the fist with the other hand.
Deliver a firm inward thrust by pulling both arms sharply backward.
Rapidly repeat the thrust 6 to 10 times as needed.
Back blows:
Wrap one arm around the waist to support the patient's upper body; small children can be laid across your legs.
Lean the person forward at the waist, about 90 degrees if possible.
Using the heel of your other hand, rapidly deliver 5 firm blows between the person's shoulder blades.
Aftercare
Patients with any symptoms remaining after foreign body removal should have a medical evaluation.
Warnings and Common Errors
These maneuvers should not be done if the choking person can speak, cough forcefully, or breathe adequately.
In obese patients and women in late pregnancy, chest thrusts are used instead of abdominal thrusts.
Tips and Tricks
The Heimlich maneuver may induce vomiting. Although vomiting may assist in dislodging a tracheal foreign body, it does not necessarily mean that the airway has been cleared.
More Information
American Heart Association: Basic Life Support (BLS) Provider Manual. Dallas, American Heart Association, 2016.
