What is the immediate management for a patient who choked on peanuts, became hypoxic and cyanotic?

Immediate Management of Foreign Body Airway Obstruction with Hypoxia and Cyanosis

For a patient who choked on peanuts and is now hypoxic and cyanotic, immediately perform back blows and abdominal thrusts (Heimlich maneuver) - do NOT delay for X-ray imaging. 1

Recognition and Immediate Action

This is a severe foreign body airway obstruction (FBAO) requiring immediate intervention. The presence of hypoxia and cyanosis indicates poor air exchange and represents a life-threatening emergency. 1

Key signs of severe obstruction include:

• Cyanosis (as present in this patient) 1
• Silent cough or inability to cough effectively 1
• Inability to speak or breathe 1
• Rapidly declining oxygen saturation 1

Step-by-Step Management Protocol

1. Immediate Obstruction Relief Maneuvers

For a conscious patient with severe FBAO:

• Administer 5 back blows first: Strike firmly between the shoulder blades with the heel of your hand while the patient leans forward 1
• If unsuccessful, perform 5 abdominal thrusts (Heimlich maneuver): Stand behind the patient, place a fist above the umbilicus, grasp with the other hand, and deliver inward and upward thrusts 1, 2
• Alternate between 5 back blows and 5 abdominal thrusts until the object is expelled or the patient becomes unconscious 1

The combination of back blows (which generate high initial pressures to dislodge objects from the larynx) followed by abdominal thrusts (which generate sustained intrathoracic pressure) is more effective than either maneuver alone. 2

2. If Patient Becomes Unconscious

• Call for emergency medical services immediately 1
• Begin CPR with chest compressions - do not check for pulse first in a choking victim who loses consciousness 1
• Before each ventilation attempt, open the mouth and look for the foreign body - remove it only if clearly visible and easily grasped 1
• Never perform blind finger sweeps as these can impact the foreign body deeper into the larynx 1

3. Continue Until Successful

• Maintain efforts until the obstruction is relieved, advanced help arrives, or the patient can be intubated 1
• Each chest compression during CPR may help dislodge the foreign body 1

Critical Pitfalls to Avoid

Do NOT obtain X-ray imaging first - this wastes precious time when the patient is already hypoxic and cyanotic. Imaging has no role in the acute management of witnessed choking with severe obstruction. 1, 3

Do NOT perform blind finger sweeps of the pharynx, as this can push the foreign body into the larynx and worsen obstruction. 1

Do NOT wait for the patient to "cough it out" when signs of severe obstruction (cyanosis, inability to speak, silent cough) are present. 1

Do NOT attempt abdominal thrusts on an unconscious patient - switch immediately to CPR with chest compressions. 1

Post-Obstruction Care

After successful removal of the foreign body:

• All patients who received abdominal thrusts must be evaluated by a physician for potential internal injuries (liver laceration, splenic injury, gastric rupture) 1, 3
• Monitor for delayed complications including aspiration pneumonia 3
• Assess for residual airway injury or retained foreign body fragments 3

Age-Specific Considerations

For infants (<1 year): Use back blows and chest thrusts (NOT abdominal thrusts) with the infant positioned head-down across your forearm. 1

For children (>1 year) and adults: Use the protocol described above with back blows and abdominal thrusts. 1