What is the appropriate treatment for a patient who is choking, considering various scenarios and potential pre-existing medical conditions such as respiratory disease?

Treatment of Choking

For a conscious choking victim with severe airway obstruction (inability to speak, breathe, or cough effectively), immediately deliver 5 sharp back blows between the shoulder blades, followed by 5 abdominal thrusts if unsuccessful, alternating between these maneuvers until the object is expelled or the victim loses consciousness. 1, 2

Recognition of Choking Emergency

Identify the severity of obstruction immediately:

• Partial obstruction: Victim is distressed and coughing but can still speak and breathe; inspiratory wheeze may be present 1
• Complete obstruction: Victim cannot speak, breathe, or cough; often grips throat with hand (universal choking sign); will progress to cyanosis and loss of consciousness 1, 2

Treatment Algorithm for Conscious Victims

If Breathing and Coughing Effectively (Partial Obstruction)

• Encourage continued coughing but do nothing else 1, 3
• Do not perform any choking maneuvers if the person can speak and breathe 3
• Monitor closely for signs of deterioration 3

If Showing Signs of Weakness, Stopped Breathing, or Complete Obstruction

Step 1: Back Blows (5 attempts)

• If standing/sitting: Stand to the side and slightly behind; support chest with one hand; lean victim well forward so dislodged object exits mouth rather than descending airway; deliver up to 5 sharp slaps between shoulder blades with heel of hand 1
• If lying: 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

Step 2: Abdominal Thrusts (5 attempts if back blows fail)

• If standing/sitting: 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 inwards and upwards 1
• If lying: Turn onto back; kneel astride victim; place heel of one hand between umbilicus and xiphisternum (avoid ribs); place other hand on top; thrust sharply downwards and toward head; give up to 5 thrusts 1

Step 3: Alternate and Reassess

• Continue alternating 5 back slaps with 5 abdominal thrusts until obstruction is relieved 1, 2
• Attempt 2 rescue breaths at the end of each series of back slaps and abdominal thrusts 1
• Recheck mouth for visible obstruction between cycles (do not perform blind finger sweeps) 1, 2

If Victim Becomes Unconscious

Immediately begin CPR:

• Open airway with head tilt-chin lift 1, 4
• Remove any visible obstruction from mouth before each ventilation attempt 1, 2
• Attempt 2 effective rescue breaths (1.5-2 seconds each, watching for chest rise) 1
• If breaths ineffective after up to 5 attempts, proceed to chest compressions 1
• Perform chest compressions at 4-5 cm depth, rate of 100/minute, with 5:1 compression-to-ventilation ratio for two-person CPR 1
• Loss of consciousness may cause laryngeal muscle relaxation, potentially allowing air passage 1

Critical Pitfalls to Avoid

• Never obtain imaging first when patient is hypoxic and cyanotic - this wastes precious time in witnessed choking with severe obstruction 2
• Never perform blind finger sweeps - this can push foreign body deeper into larynx and worsen obstruction 2
• Never give anything to eat or drink - may trigger more coughing or bleeding 3
• Never have victim lie flat if hemoptysis occurs - increases aspiration risk 3

Post-Obstruction Management

All patients who received abdominal thrusts must be evaluated by a physician for potential internal injuries:

• Liver laceration, splenic injury, or gastric rupture are possible complications 2
• If hemoptysis occurs after choking, keep person upright and leaning slightly forward while awaiting emergency services 3
• Monitor for delayed complications including mucosal injury, unstable clot formation, and progressive bleeding over hours 3

High-Risk Features Requiring Immediate Emergency Activation

Call emergency services immediately if any of the following develop:

• Signs of shock (rapid pulse, pale/clammy skin, confusion, weakness) 3
• Difficulty breathing or speaking 3
• Loss of consciousness 3
• Cyanosis with hypoxia despite initial maneuvers 2

Age-Specific Modifications

• Infants (<1 year): Use back blows and chest thrusts (NOT abdominal thrusts) with infant positioned head-down across forearm 2
• Children (>1 year) and adults: Use protocol described above with back blows and abdominal thrusts 2

When Standard Maneuvers Fail

If back blows and abdominal thrusts fail and patient deteriorates to unconsciousness with "can't intubate, can't ventilate" status:

• Emergency cricothyroidotomy may be necessary 2
• Prepare for definitive airway management with immediate anesthesia/airway expert assistance 4