What is the first step in managing a case of suspected choking?

Management of Suspected Choking

The first step in managing a case of suspected choking is to deliver five sharp back blows to the middle of the back while holding the victim in a prone position with the head lower than the chest. 1

Initial Assessment and Recognition

• Quickly recognize signs of severe airway obstruction: silent cough, cyanosis, inability to speak or breathe, and the universal choking sign (victim clutching their neck) 1
• Ask "Are you choking?" - if the victim nods without speaking, this confirms severe airway obstruction 1
• Never perform blind finger sweeps of the pharynx as these can impact a foreign body further into the larynx 1

Management Algorithm for Adults

Step 1: Back Blows

• Deliver five sharp blows to the middle of the back 1
• Position the victim in a prone position with head lower than chest 1
• For a standing victim, stand slightly behind them and support their chest with one hand 1

Step 2: Abdominal Thrusts (Heimlich Maneuver)

• If back blows are unsuccessful, proceed to abdominal thrusts 1
• For conscious adults, use the upright position (Heimlich maneuver) 1
• Place the heel of one hand in the middle of the upper abdomen, directed upwards toward the diaphragm 1
• Deliver five sharp upward thrusts 1
• Be aware that incorrect technique can cause complications such as gastric rupture 2

Step 3: Check Mouth

• After five back blows and five abdominal thrusts, check the mouth 1
• Remove any visible foreign bodies 1

Step 4: Repeat Cycle

• Continue alternating between back blows and abdominal thrusts until the airway is cleared 1

Management Algorithm for Infants (<1 year)

• Hold the infant along the forearm with head lower than chest 1
• Deliver five back blows 1
• Turn infant to supine position with head lower than chest 1
• Perform five chest thrusts (NOT abdominal thrusts) 1
• Chest thrusts should be sharper and at a more vigorous rate than CPR compressions (about 20 per minute) 1
• Abdominal thrusts are NOT recommended in infants due to risk of rupturing abdominal viscera 1

For Unconscious Victims

• If the victim becomes unconscious, place them on their back 1
• Open the airway using head tilt-chin lift maneuver 1
• Look for visible obstructions in the mouth and remove if seen 1
• Attempt rescue breathing - if unsuccessful, reposition the head and try again 1
• If breathing cannot be established, begin CPR with chest compressions 1

Special Considerations

• Risk factors for choking include neurological disorders, dysphagia, and dental issues 3, 4
• Elderly patients and those on CNS-acting medications (antipsychotics, antiepileptics) are at higher risk of choking due to impaired swallowing 4
• In care home settings, airway clearance devices may be considered as an adjunct to standard procedures when conventional methods are ineffective 5

Common Pitfalls to Avoid

• Delaying intervention - choking is a time-critical emergency requiring immediate action 6
• Performing blind finger sweeps which may push the object deeper 1
• Using abdominal thrusts in infants 1
• Applying excessive force during abdominal thrusts, which can cause internal injuries 2
• Failing to activate emergency medical services if initial attempts to clear the obstruction are unsuccessful 1