Choking is the body's natural response to sudden airway obstruction. Foreign body airway obstruction (FBAO) causes asphyxia (severe drop in the oxygen level reaching the body) and is a terrifying condition, occurring very acutely, with the patient often unable to explain what is happening to them. If severe, it can result in rapid loss of consciousness and death if first aid is not undertaken quickly and successfully. Immediate recognition and response are of the utmost importance.
Choking due to inhalation of a foreign body usually occurs whilst eating; it need not have been a formal 'sit-down' meal - a snack eaten 'on-the-go' or chewing gum can also be inhaled.
Because recognition is the key to successful outcome, it is important to ask the conscious victim "Are you choking?" This at least gives the victim who is unable to speak the opportunity to respond by nodding!
Consider the diagnosis of choking particularly if:
- Episode occurs whilst eating, and onset was very sudden.
- Adult victim - may clutch his or her neck, or points to throat.
- Child victim - there may be clues, e.g. seen eating or playing with small items just before onset of symptoms.
- The patient is able to breathe, cough effectively and speak.
- Children are fully responsive, crying or verbally respond to questions, may have loud cough (and able to take a breath before coughing).
- Victim unable to breathe or speak/vocalize.
- Wheezy breath sounds.
- Attempts at coughing are quiet or silent.
- Cyanosis (bluish color to the skin and lips) and diminishing conscious level (particularly in children).
- Victim unconscious.
In mild obstruction, encourage the patient to continue coughing, but do nothing else except monitor for deterioration.
In severe obstruction in a conscious patient:
- Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim well forwards (so that the obstructing object comes out of the mouth rather than going further down the airway).
- Give up to five sharp back blows between the shoulder blades with the heel of your other hand (checking after each if the obstruction has been relieved).
- If unsuccessful, give up to five abdominal thrusts. Stand behind the victim (who is leaning forward) put both arms around the upper abdomen and clench one fist, grasp it with the other hand and pull sharply inwards and upwards.
- Continue alternating five back blows and five abdominal thrusts until successful or the patient becomes unconscious.
In an unconscious patient:
- Lower the patient to the floor.
- Call an ambulance immediately.
- Begin CPR (even if a pulse is present in the unconscious choking victim).
- If coughing effectively, just encourage the child to cough, and monitor continuously.
- If coughing is, or is becoming, ineffective, shout for help and assess the child's conscious level.
- If the child is conscious, give up to five back blows, followed by five chest thrusts to infants or five abdominal thrusts to children (repeat the sequence until the obstruction is relieved or the patient becomes unconscious).
For infants (< 1 year old): back blows and chest thrusts:
- In a seated position, support the infant in a head-downwards, prone position (facing downwards) to let gravity aid removal of the foreign body.
- Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers from the same hand at the same point on the other side of the jaw. Do not compress the soft tissues under the jaw, as this will aggravate the airway obstruction.
- Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the shoulder blades).
- After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the maneuver up to five times.
- After five unsuccessful back blows, use chest thrusts: turn the infant into a head-downwards supine position (facing upwards) by placing your free arm along the infant's back and encircling the occiput (back of the head) with your hand. Support the infant down your arm, which is placed down (or across) your thigh. Identify the landmark for chest compression. This is the lower sternum (bone in the middle of the chest). Deliver five chest thrusts. These are similar to chest compressions for CPR, but sharper in nature and delivered at a slower rate.
For children (1 year old to puberty): back blows and abdominal thrusts:
- Blows to the back are more effective if the child is positioned head down. A small child can be placed across the lap as with an infant. If this is not possible, support the child in a forward-leaning position.
- Deliver up to five sharp back blows with the heel of one hand in the middle of the back between the shoulder blades.
- After five unsuccessful back blows, abdominal thrusts may be used in children over 1 year old:
- Stand or kneel behind the child, placing arms around torso. Placed clenched fist between the umbilicus and xiphisternum (lower end of the chest bone)ensuring no pressure is applied to either landmark
- Grasp this hand with your other hand and pull sharply inwards and upwards, repeating up to 5 times.
- If the child becomes unconscious, place him or her on a flat, firm surface, shouting for help if none has arrived. Open the mouth and look for any obvious object. If one is seen, make an attempt to remove it with a single finger sweep (don't do blind finger sweeps).
- If unsuccessful, begin pediatric basic life support, beginning with five rescue breaths, checking for rise and fall of the chest each time (reposition the head each time if a breath does not make the chest rise, before making the next attempt).