Is a cricothyroid (cric) puncture with a pen indicated if the Heimlich maneuver fails?

Cricothyroid Puncture with a Pen is NOT Indicated After Failed Heimlich Maneuver

If the Heimlich maneuver fails in a choking victim, you should continue CPR with chest compressions and attempt to visualize and remove the foreign body—NOT perform cricothyroid puncture with a pen. A pen is an improvised, unreliable device that lacks the necessary characteristics for effective emergency airway access and should never be used for this purpose.

The Correct Algorithm for Failed Heimlich Maneuver

For Children (Age >1 year)

• Continue abdominal thrusts (Heimlich maneuver) until the object is expelled or the victim becomes unresponsive 1
• If the victim becomes unresponsive, immediately start CPR with chest compressions (do not check for pulse) 1
• After 30 chest compressions, open the airway and look for the foreign body 1
• If you see the foreign body, remove it—but never perform blind finger sweeps as these can push the object deeper 1
• Attempt 2 rescue breaths, then continue cycles of 30 compressions and 2 breaths 1
• After 2 minutes of CPR, activate emergency medical services if not already done 1

For Infants (<1 year)

• Deliver 5 back blows followed by 5 chest compressions in repeated cycles until the object is expelled or the infant becomes unresponsive 1
• Never perform abdominal thrusts in infants due to risk of liver injury 1
• If unresponsive, follow the same CPR algorithm as above 1

Why Cricothyroid Puncture is NOT the Next Step

Cricothyroidotomy is Reserved for "Cannot Intubate, Cannot Ventilate" (CICV) Situations

• Cricothyroidotomy is indicated only when trained personnel cannot achieve ventilation by any other means (endotracheal intubation, bag-mask ventilation, or supraglottic airway devices have all failed) and severe hypoxemia with bradycardia is present 1, 2
• This is a hospital/advanced EMS procedure, not a bystander intervention 1

A Pen is Completely Inadequate for Emergency Airway Access

• Proper cricothyroidotomy requires either a kink-resistant cannula with high-pressure jet ventilation OR surgical cricothyroidotomy with a cuffed tube 1
• Standard improvised devices like pens are easily kinked and cannot provide effective ventilation 1
• Even proper cannula cricothyroidotomy has reported low success rates and requires high-pressure oxygen sources (not available outside hospitals) 1
• A pen lacks the ability to deliver adequate minute ventilation and has no mechanism for securing the airway or preventing dislodgement 1

CPR Chest Compressions Can Dislodge Foreign Bodies

• The chest compressions performed during CPR generate intrathoracic pressure that may help expel the foreign body 1
• This is why the guideline specifically directs you to check for and remove visible foreign bodies after each cycle of compressions 1

When Cricothyroidotomy IS Actually Indicated (For Context)

Cricothyroidotomy should only be performed by trained medical personnel in true CICV situations:

• After multiple failed intubation attempts by skilled providers 1, 2
• When bag-mask ventilation and supraglottic airways have failed 1, 2
• In the presence of severe hypoxemia, especially with bradycardia 1, 2
• With proper equipment: either a kink-resistant cannula with jet ventilation OR surgical technique with scalpel and cuffed tube 1, 2

The Proper Technique (When Indicated by Trained Personnel)

• Surgical cricothyroidotomy with a scalpel and vertical incision is now preferred over cannula techniques 1, 2
• Pre-identification of the cricothyroid membrane with ultrasound improves success rates, especially in difficult anatomy 1, 2, 3, 4
• These techniques have serious complications and should only be used in life-threatening situations 1, 2

Critical Pitfalls to Avoid

• Never abandon effective CPR to attempt an improvised airway procedure you are not trained to perform 1
• Never perform blind finger sweeps—they can push the foreign body deeper into the airway 1
• Do not delay activating emergency medical services 1
• Recognize that even the Heimlich maneuver itself can cause complications (pneumomediastinum, surgical emphysema) but remains the recommended first-line intervention 5

The bottom line: Continue CPR with chest compressions and airway checks until advanced medical help arrives. Cricothyroid puncture with a pen is not part of any evidence-based choking algorithm and should never be attempted.