What is the proper technique for performing the Heimlich maneuver (abdominal thrusts) on someone who is choking?

Heimlich Maneuver Technique

For a conscious adult or child over 1 year with complete airway obstruction, perform abdominal thrusts by standing behind the victim, placing a fist between the umbilicus and xiphisternum, grasping it with your other hand, and pulling sharply inward and upward to expel the foreign body. 1

Initial Assessment

Distinguish between partial and complete obstruction immediately:

• Partial obstruction: Victim is distressed, coughing, may have inspiratory wheeze but can still breathe 1
• Complete obstruction: Victim cannot speak, breathe, or cough; often grips throat with hand (universal choking sign); will lose consciousness if untreated 1, 2

Management Algorithm

For Partial Obstruction

• Encourage continued coughing and do nothing else 1, 2
• Do not interfere with the victim's own efforts to clear the airway 1

For Complete Obstruction in Adults and Children Over 1 Year

The current recommendation is to alternate 5 back slaps with 5 abdominal thrusts (Heimlich maneuver). 2

Back Slaps Technique:

• Standing/sitting victim: Stand to the side and slightly behind, support chest with one hand, lean victim well forward, deliver up to 5 sharp slaps between shoulder blades with heel of other hand 1
• Lying victim: Kneel beside victim, roll onto side facing you, support chest with your thigh, deliver up to 5 sharp slaps between shoulder blades 1
• Aim to relieve obstruction with each slap rather than necessarily giving all five 1

Abdominal Thrusts (Heimlich Maneuver) Technique:

• Standing/sitting victim: Stand behind victim, place both arms around upper abdomen, ensure victim bends well forward, clench fist and place between umbilicus and xiphisternum, grasp with other hand, pull sharply inward and upward 1, 2
• Lying victim: Turn onto back if necessary, kneel astride victim, place heel of one hand between umbilicus and xiphisternum (avoid pressure on ribs), place other hand on top, thrust sharply downward and toward victim's head, repeat up to 5 times 1

Cycling Protocol:

• Alternate 5 back slaps with 5 abdominal thrusts 2
• Attempt 2 rescue breaths at the end of each cycle 2
• Check mouth after each cycle and remove any visible object 2
• Continue alternating until obstruction is relieved or victim becomes unconscious 1, 2

Special Consideration: Infants Under 1 Year

Do NOT perform abdominal thrusts on infants due to risk of rupturing abdominal viscera. 2

• Use 5 back slaps alternating with 5 chest compressions instead 2
• Place infant prone with head lower than torso for back slaps 2
• Perform chest compressions similar to cardiac compressions but more vigorously at approximately 20 per minute 2

If Victim Becomes Unconscious

Immediately transition to basic life support sequence: 1, 2

• Open airway by lifting chin and tilting head 1
• Check for breathing by looking, listening, and feeling 1
• Remove any visible obstruction from mouth 1
• Loss of consciousness may cause laryngeal muscle relaxation, potentially allowing air passage 1

Critical Pitfalls and Complications

While the Heimlich maneuver is lifesaving, be aware of potential complications, particularly in elderly patients:

• Rib fractures, gastric or esophageal perforation are most common 3
• Rare but serious complications include splenic rupture, hepatic rupture, pneumomediastinum, pneumopericardium, and gastric rupture 4, 3, 5
• Apply the technique carefully in elderly patients who are at higher risk for complications 6
• Distinguish choking from esophageal food impaction, as the Heimlich maneuver can cause serious complications when applied inappropriately to food impaction 6
• Despite potential complications, the maneuver remains justified as the alternative is asphyxiation and death 5

Key Technical Points

• Always lean the victim forward during both back slaps and abdominal thrusts so the dislodged object exits the mouth rather than traveling deeper into the airway 1, 2
• Position hands precisely between umbilicus and xiphisternum to minimize injury risk 1
• Avoid direct pressure on ribs or xiphoid process 1
• Use sharp, forceful movements rather than gradual pressure 1