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Lean the patient forward and give up to five blows between the shoulder blades with the heel of your other hand.
Although choking (foreign body airway obstruction - FBAO) is common, the exact incidence is unknown, as most cases are relieved spontaneously or with the help of an onlooker. Studies on the best means of emergency management are scarce, with most publications consisting of case histories and anecdotes.
Immediate treatment of choking consists of measures to increase intrathoracic pressure, thus forcing the obstructing material upwards and outwards.
Three such methods described are abdominal thrusts (Heimlich manoeuvre), back blows (or slap) and chest thrusts (similar to chest compressions during CPR, but sharper in nature and delivered at a slower rate).
There is no convincing evidence that one technique is better than another, but several reports have suggested that it often takes more than one, in sequence, to achieve the desired result.
The following guidelines for the management of choking are taken from the Resuscitation Council (UK) Resuscitation Guidelines 2015.
Recognition is the key to a successful outcome. It is important not to confuse this emergency with other conditions that may cause sudden respiratory distress, cyanosis, or loss of consciousness.
An attack often occurs whilst eating and the patient may clutch at their neck. A child may be seen to put an object into the mouth. Ask a conscious patient if they are choking.
Signs of airway obstruction
Mild airway obstruction
- Patient is able to speak, cough and breathe, and answers ‘yes’ when asked if choking
Severe airway obstruction
- Patient is unable to speak
- Patient may respond by nodding ‘yes’ when asked if choking
- Patient is unable to breathe
- Breathing sounds wheezy
- Attempts at coughing are silent
- Patient may be unconscious
Adult choking sequence
The sequence below is suitable for adults and children over the age of one year.
1. If the patient shows signs of mild airway obstruction, encourage him or her to continue coughing, but do nothing else.
2. If the patient shows signs of severe airway obstruction and is conscious, give up to five back blows.
- Stand to the side and slightly behind the patient.
- Support the chest with one hand and lean the patient forward, so that when the obstructing object is dislodged it comes out of the mouth rather than going further down the airway. Small children may be supported on the rescuer’s lap or knee in a head-downwards, prone position, to enable gravity to assist removal of the foreign body.
- Give up to five blows between the shoulder blades with the heel of your hand.
- Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than necessarily to give all five.
- If five back blows fail to relieve the obstruction, give up to five abdominal thrusts.
- Stand behind the patient and put both arms around the upper part of his abdomen.
- Lean the patient forward.
- Place your clenched fist between the umbilicus and the bottom end of the sternum.
- Grasp this hand with your other hand and pull sharply inwards and upwards.
- Repeat up to five times.
- If the obstruction is still not relieved, continue alternating five back blows with five abdominal thrusts.
Abdominal thrusts should not be carried out on infants under the age of one year for fear of causing intra-abdominal organ damage. Instead, if five initial back blows fail, turn the infant onto their back and give up to five chest thrusts. These are similar to chest compressions, but sharper in nature and delivered at a slower rate.
3. If the patient becomes unconscious, support him or her carefully to the ground. Immediately call an ambulance. Then begin CPR with 30 chest compressions followed by two attempts at rescue breathing, and repeat the sequence. The compressions are designed to relieve the obstruction even if cardiac arrest has not yet occurred.
Following successful relief of obstruction, the foreign body may remain in the upper or lower respiratory tract and cause later complications. Patients with a persistent cough, difficulty swallowing or with the sensation of an object being still stuck in the throat should be referred.
Abdominal thrusts can cause internal injuries and all patients receiving abdominal thrusts should be examined for injury.
If these manoeuvres all fail, and the equipment and expertise are available, a foreign body may be removed by forceps under direct vision.
- Dr Anthony Handley is honorary consultant physician, Colchester Hospitals University NHS Trust, Colchester, United Kingdom, and board director of the European Resuscitation Council, past chairman of the Resuscitation Council