How to care for an adult or child (over the age of 1) who is choking

Having already assessed whether a person is conscious or not will now mean that you are able to safely approach a person who is choking in the correct manner and start providing first aid care. How you approach an infant versus a child, adolescent or adult also differs and for good reason.

An adult or child who is conscious but in a life-threatening state due to an airway obstruction will need to be assisted with abdominal thrusts, a first aid technique known as the Heimlich Manoeuvre. This first aid technique is not recommended if a person is able to cough forcefully or speak.

Did you know? The Heimlich Manoeuvre was invented by thoracic surgeon and medical researcher Dr Henry Judah Heimlich. Until he introduced the technique in the 70’s, choking was remedied by slapping a person’s back which was ineffective and often made matters worse by forcing the object further down the airway. In those days choking was the sixth most common cause of death in the United States.

At the age of 96, Dr Heimlich himself used his technique to save the life of a female resident at the retirement home he lived at in Cincinnati, USA. He swiftly assisted when he noticed that she was choking at a communal dining room table and used his technique to dislodge the piece of meat and bone caught in her airways.

As you approach a choking person while assessing their condition, you must determine this. If unsure, you can ask direct questions, like “Are you able to speak?” An inability to cough, speak or breathe are clear indicators that assistance is needed. Performing the Heimlich (which is effectively a forceful, sharp action) if a person is capable of forcing a cough on their own can injure them unnecessarily.

The Heimlich Manoeuvre is a method of abdominal compressions or thrusts, which creates an artificial cough, where a person is unable to force one themselves. The action forces the diaphragm towards the lungs which expel enough air to dislodge the obstruction from the airway (windpipe), and expel it through the mouth, finally allowing a person the ability to breathe again. The stimulated artificial cough effectively replaces the natural action the affected person is unable to perform themselves.

The average 5-minute timeline for emergency reaction is critical. Assistance to dislodge the obstruction must occur within this timeframe in order to prevent more serious injury and breathing trouble, as well as loss of consciousness.

The Heimlich Manoeuvre is forceful but tailored to ensure that the ribs and internal organs do not experience extensive injury. Knowing how to perform the technique accurately is therefore important to learn for use in such situations.

A child that is over the age of 1 can be attended to in much the same way as an adult. You will just need to be mindful of their size, adjust positioning accordingly and be aware of your own strength (taking care not to be unnecessarily forceful).

During the assessment process of the choking individual and the surrounding environment, you may note quite a bit of anxiety or distress, especially when it comes to children. Children typically react to stressful situations much like the adults might who are around them. If an adult is particularly emotional or panicked, a child who is choking is likely to react in a similar manner. You may need to calm down distressed individuals or enlist the help of a bystander to help ease the panic. With little time to spare, spending precious minutes calming everyone is not ideal. Do your best to be a calming and assertive influence and make use of others where you can.

How you approach a small child will be strongly influenced by their age, so you must take careful note of their development stage. Children may not understand what is happening to them and their development stage may influence an initial reaction to your approach.

Toddlers (1 to 3 years of age) or pre-schoolers (aged 3 to 5) may become particularly anxious when separated from a loved one or familiar individual. Children of school-going age (aged 5 and upwards) are a little more comfortable with strangers (if you are a stranger to them) and understand any instructions given to them (if you speak directly to a child, ensure that you use age appropriate language). Teenagers / adolescents may be a little self-conscious about their changing bodies, so it is good to keep this at the back of your mind too.

Play things by ear as no two emergency situations are entirely alike but do all you can not to allow precious time to be wasted.

1. Assisting a choking adult or child who is conscious

Standard life-saving practice involves ‘back slaps’ or ‘blows’ as well as abdominal thrusts (the Heimlich Manoeuvre). The objective for both is exactly the same, to help dislodge the obstruction, and these actions can be performed in an alternating combination (sets of 5 and 5 ⁽²⁾ – Note: Various first aid accredited courses or official information providers stipulate differing set numbers. Some stipulate 5, others between 6 and 10 ⁽³⁾

If you are participating in a training course, administer the process as stipulated in the updated version you are training in. Otherwise, as long as alternate sets are repeated in the correct motion, this should be effective to assist a choking individual.

• Performing back slaps / blows: Position yourself behind or slightly to the side of a person who is upright. Ensure that your own weight is evenly distributed and sturdy. Provide support to the individual by placing one arm around and across their chest area. With your free hand, bend the person forward (from the waist), almost parallel to the ground. A back slap should never be given when a patient is upright – this can cause the obstruction to slip further down the windpipe.
  Using the heel of your free hand, strike the person between the shoulder blades a total of 5 to 10 times (forcefully but not too hard). Each blow must be separate from the other and not done too quickly.
• Abdominal thrusts / compressions: After the last back blow, move into position for the Heimlich Manoeuvre. These are inward and upward thrusts from just above the navel area (just below the rib cage / beneath the diaphragm). Still positioned behind the person, ensure that you are in a stable stance (standing or kneeling depending on a person’s height). To do this, place one foot (or knee) in front of the other and ensure that you are comfortable enough to remain balanced and stable while implementing the abdominal thrusts. Wrap both arms around the person at waist level (off the rib cage as much as possible). Place one or two fingers from one hand on the individual’s navel. With your other hand, ball it up into a fist, and place the thumb side (against the person’s abdomen) just above the finger/s on the navel. Now with the other hand (the one which had a finger/s on the navel), cover the fist in a firm grip. Now, think ‘inward’ and ‘upward’ – this is the thrust / compression motion of the Heimlich method. Give 5 to 10 quick (sharp), but separate inward and upward thrusts to the abdomen. 

After the last abdominal thrust, give a set of back blows, alternating the two means of dislodging the obstruction until the person is able to cough forcefully on their own (ridding the body of the obstruction in the process), attempts to speak or cry, or falls unconscious (becomes unresponsive).

You may need to improvise these movements based on the position of the person choking. Should a person be in a seated position or if they are a child who is shorter or smaller than you are, you will need to kneel in order to comfortably provide care.

If a person is lying down, but still conscious, you can also position yourself to assist with abdominal compressions / thrusts as you would if they were unconscious (see the below description for more). Give thrusts in sets of 5 to 10, repeating as necessary, paying attention to their breathing capacity, until the obstruction dislodges, and the person is either able to cough or speak on their own, or falls unconscious.

2. Assisting an adult or child who is unconscious

If you are sure that a person has fallen unconscious as a result of choking at the time of approaching them, the following technique for dislodging the obstruction may be used.

Note: You may need to adjust a person’s body position. In order to assist, ensure that they are lying flat on their back, with their neck and head straight, and arms at their side.

• Finger sweep: Check to see if you can see an obstruction in a person’s mouth. Gently (and quickly) part a person’s lips with a thumb and index finger and look inside their mouth. You may need to place your thumb gently on the tip of the tongue, holding your index finger at the chin. If you can see a loose object (obstruction) in the mouth, hook a finger, carefully place it inside the mouth and sweep it across the tongue to remove the object. Only attempt a finger sweep if you can see an object and determine that it can be removed safely with a sweep (and not pushed backwards into the throat). You may see something at the back of a person’s mouth (throat). Do not try and finger sweep it as this can cause it to slip down the throat and further obstruct the person’s airway. If you cannot see an obstruction, lift the person’s chin slightly, tilting the head backwards a little to help open the airway. Note, a finger sweep is not recommended for a child under the age of 8. Rather use a tongue-jaw lift technique to open the mouth and look inside, by placing your thumb inside the mouth of the child and your fingers in a holding position along his or her chin. Only if an obstruction is clearly loose and can be safely removed, do so.
• Abdominal thrusts / compressions: A person who is unconscious is unable to breathe, but because of the obstruction in the airway, you will need to assist by beginning with compressions to remove it before attempting rescue breathing (CPR). Position yourself over the person’s legs, facing the top end of the person and placing their arms comfortably at their sides. Lower yourself to straddle them and place the heel of one of your hands just above the waistline (navel). Now place the other hand on top of the already positioned one, ready to administer ‘inward’ and ‘upward’ thrusts. While giving the thrusts, try to keep your elbows straight – this enables the motion. Give abdominal thrusts in sets of 5 to 10 until the obstruction is dislodged and comes out through the mouth (or until advanced life support can be given by EMS professionals).
• Take note of breathing capacity (rescue breathing): If the obstruction is expelled and EMS professionals have not yet arrived, you will need to start CPR techniques. Lower your head towards to the person and listen (with an ear close to the person’s mouth) for indications of breathing. Watch the chest to determine any rise and fall (with an obstruction expelled, a person should have some slight breathing capacity). This should not take longer than 5 seconds to determine. Begin rescue breathing by gently pinching the person’s nostrils with a thumb and index finger. Cover your mouth over the person’s (you can use a CPR barrier device or portable mask if you carry one of your own) and give two full, slow breaths, pausing briefly in between. Watch a person’s chest while giving these breaths to check if the chest rises. If not, check the position of the person’s head and ensure that the airway is still open (chin up and head titled backwards), and attempt two more slow, full breaths. Check the person’s pulse. If you cannot feel a pulse, you will need to give 30 chest compressions. ⁽⁴⁾ Check the person’s mouth once more to ensure that no other foreign object remains. If there are any loose bits, perform a finger sweep to remove them. Return to rescue breathing (two full breaths), followed by chest compressions.

Continue in cycles of checking the mouth, ensuring that the head is in an open airway position, giving rescue breaths and chest compressions until EMS assistance arrives or the individual begins breathing again on their own (regaining consciousness). Do not leave the patient alone at any point before EMS professionals arrive.

3. After the obstruction is cleared from the airways

Once the airway obstruction is expelled a person, whether consciousat the time of first aid care or not, must be examined by a medical professional as soon as possible. Even if a person is able to breathe and speak normally a short while after the choking incident, they must be evaluated by a physician.

Once EMS professionals arrive, they will conduct a preliminary evaluation of the person and begin providing care for transport to a medical facility.

The nature of the Heimlich Manoeuvre and CPR techniques do involve forceful contact with the body and can thus cause some degree of injury to a person. This is why the techniques should only be used in emergency scenarios.

A medical doctor will double check for the possibility of further injury or complications (to the airways and/or internal organs) due to either the choking experience or administered first aid assistance, or both, and treat these accordingly.

Considerations for special situations

From initial observations before administering first aid care, you may note some of the following possibilities which will impact your ability to assist:

• A person may be too large to comfortably wrap your arms around: A person that is a little too large in size for you to get your arms completely around or is obese will create some difficulty with the standard Heimlich Manoeuvre technique. Instead of abdominal thrusts / compressions, you may need to administer the chest variation instead. The process for positioning is much the same, but instead of finding the navel (which is often at the widest portion of the body), you will need to place a thumb side fist against the breastbone (centre of the chest). Covering the fist with the other hand, pull thrusts inwards and upwards as you would have done if administering them to the abdomen. The same process will apply to a woman who may be obviously pregnant (or known to be in early stages of pregnancy).
• A person has a physical disability and is in a wheelchair: A person who is choking while positioned in a wheelchair need not frighten you. Try to make sure that the chair is reasonably secure and position yourself (kneeling) behind the person and their wheelchair in much the same manner as you would another in a more usual seated position. If features of the wheelchair get in the way or make it difficult for you to administer abdominal thrusts, don’t panic. You can try the chest compression variation instead.

References:

^{2. Victoria State Government - Better Health Channel. August 2014. Choking: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/choking [Accessed 01.12.2017]}

^{3. University of Rochester Medical Center. Choking and Abdominal Thrusts: https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&ContentID=P00825 [Accessed 01.12.2017]}

^{4. MedlinePlus. December 2017. Choking - unconscious adult or child over 1 year: https://medlineplus.gov/ency/article/000051.htm [Accessed 01.12.2017]}