EMERGENCY AID: PERFORMING ABDOMINAL THRUSTS FOR CHOKING ADULTS

The immediate management of a foreign body airway obstruction (FBAO), commonly known as choking, is one of the most critical emergency interventions required in pre-hospital care. Choking is a time-sensitive event; lack of oxygen can lead to irreversible brain damage within four to six minutes. For the conscious, non-infant adult experiencing severe choking, the established protocol involves a series of life-saving measures, centered on generating a rapid, forceful elevation of the diaphragm to compress the lungs and create an artificial cough. This action is achieved through abdominal thrusts, often referred to as the Heimlich maneuver.

Context and Initial Assessment

The decision to intervene with abdominal thrusts must be based on a clear assessment of the victim’s condition. Intervention is only appropriate when the obstruction is severe.

A. Recognizing Severe Choking

1. Assess the Severity of the Obstruction:
   • Mild Obstruction: The victim can still speak, cough forcefully, and breathe. Encourage them to continue coughing naturally, but do not intervene with thrusts or blows, as a forceful cough is the most effective way to dislodge the object.
   • Severe Obstruction (The Need for Intervention): The victim exhibits signs of ineffective airway clearance. These signs include:
     • Inability to speak, make sounds, or cry.
     • A silent or weak cough.
     • Difficulty breathing, often accompanied by high-pitched noises (stridor) or total silence.
     • The universal sign of choking: clutching the hands to the throat.
     • Cyanosis (bluish discoloration of the lips, face, or nail beds) due to oxygen deprivation.
2. Immediate Action:
   • If severe choking is confirmed, immediately inform the victim that you are trained and prepared to help.
   • Activate Emergency Services: If a bystander is present, instruct them to call emergency medical services (EMS), typically 9-1-1 in the United States, immediately. If you are alone, intervention should precede calling EMS, but be prepared to call if the victim becomes unconscious.

The Standard Protocol: Back Blows and Abdominal Thrusts

Current resuscitation guidelines often recommend an alternating cycle of five back blows followed by five abdominal thrusts until the obstruction is relieved or the victim becomes unconscious.

A. Performing Five Back Blows (Initial Phase)

While abdominal thrusts are the focus, the back blow phase is an integral starting component of the accepted cycle.

1. Positioning: Stand slightly to the side and behind the victim. If possible, have the victim lean forward slightly. This position ensures that when the foreign object is dislodged, gravity helps it travel out of the airway rather than deeper into the throat.
2. Execution: Use the heel of one hand to deliver five separate, distinct, and forceful blows between the victim’s shoulder blades (scapulae).
3. Assessment: After the five blows, quickly assess if the object has been dislodged. If not, proceed immediately to abdominal thrusts.

B. Performing Five Abdominal Thrusts (Heimlich Maneuver)

If back blows are ineffective, the rescuer must transition immediately to abdominal thrusts. The mechanism relies on generating pressure that forces residual air in the lungs upward.

Step 1: Positioning the Rescuer and Victim

1. Stand Behind the Victim: Approach the victim from behind, wrapping your arms around their waist. Ensure the victim is standing firmly; if they appear unsteady, brace their body against yours.
2. Establish Stability: Separate your feet and stand wide, with one foot placed slightly between the victim’s feet. This stance provides a sturdy base, allowing you to support the victim if they lose consciousness.

Step 2: Hand Placement and Fist Formation

Precise hand placement is critical to maximize effectiveness while minimizing the risk of internal injury.

1. Locate the Abdominal Landmark: Find the victim’s navel (umbilicus). The target area for the thrust is significantly above the navel, within the epigastric region.
2. Fist Placement: Form a tight fist with one hand. Place the thumb side of this fist against the victim’s abdomen, centered just above the navel and well below the lower end of the breastbone (xiphoid process). Placing the fist too high could lead to direct injury to the ribs or the xiphoid process, potentially causing severe internal trauma.
3. Grasp the Fist: Wrap your other hand firmly around the fist. Ensure your elbows are held out and away from the victim’s ribs to concentrate the force of the thrust onto the diaphragm.

Step 3: Executing the Thrusts

The thrust motion is distinct from a simple squeeze or push; it must be focused and directional.

1. The Thrusting Action (The “J” Motion): Deliver five rapid, distinct, and forceful thrusts. The motion should be inward (drawing the victim toward you) and upward (thrusting toward the victim’s chest/head). This combination of inward and upward force compresses the abdomen, pushes the diaphragm up, and rapidly increases intrathoracic pressure.
2. Force and Speed: Each thrust should be delivered with the intention of dislodging the object. Ensure that each thrust is a separate effort, allowing time to reset slightly, rather than a continuous squeeze.
3. Maintenance of Control: Maintain a strong grip on the victim throughout the sequence to prevent them from falling if the thrusts cause them to lose balance.

Step 4: Repetition and Reassessment

1. The Cycle: Continue the alternating cycle of five back blows and five abdominal thrusts without hesitation.
2. Reassessment: After each sequence of five thrusts, quickly check the victim’s mouth. If you see the object, remove it carefully with a finger (only if visible—blind sweeps risk pushing the object deeper). Do not interrupt the cycle unless the object is expelled or the victim becomes unconscious.

Special Considerations

Standard abdominal thrusts are contraindicated in certain populations, requiring a modification of the procedure to maintain safety and efficacy.

A. Pregnant or Obese Victims (Chest Thrusts)

If the victim is pregnant (especially in the late stage) or too large for the rescuer to wrap their arms comfortably around the waist, abdominal thrusts are replaced by chest thrusts. The principle remains the same—to compress the lungs—but the location of force changes.

1. Positioning: Stand behind the victim, positioning your arms directly under the armpits, wrapping them around the chest instead of the abdomen.
2. Fist Placement: Place the thumb side of your fist on the center of the breastbone (sternum), ensuring it is placed appropriately over the sternum, avoiding the very edges or the lower ribs.
3. Execution: Grasp the fist with the other hand and deliver five forceful, inward thrusts directly backward (not upward).

B. Loss of Consciousness

If the conscious adult victim becomes unresponsive while choking, the intervention protocol changes immediately:

1. Lower the Victim: Gently and quickly lower the victim to the ground.
2. Activate EMS: If this has not already been done, call EMS immediately.
3. Start CPR: Initiate Cardiopulmonary Resuscitation (CPR). Each time the rescuer opens the airway to deliver rescue breaths, look inside the mouth for the obstructing object. If it is visible, remove it. Chest compressions performed during CPR serve the dual purpose of circulating blood and potentially dislodging the foreign object.

C. Self-Administering Thrusts

If an individual is choking alone, they can attempt to administer thrusts to themselves.

1. Fist Placement: Form a fist and place it above the navel. Grasp the fist with the other hand.
2. Execution: Thrust the fist inward and upward forcefully.
3. Leverage: Alternatively, lean over a hard horizontal surface (e.g., the back of a chair, a railing, or a countertop). Position the upper abdomen over the edge and execute a rapid, forceful thrust against the object to generate the necessary pressure.

Post-Intervention Care

Once the choking object has been successfully dislodged, the crisis may appear over, but medical evaluation is still mandatory.

1. Assessment after Relief: Check the victim’s breathing and consciousness. If they are breathing normally and are fully conscious, reassure them.
2. Medical Follow-up: Even if the object is expelled and the victim appears fine, they must be transported to a hospital or examined by a medical professional immediately. Forceful abdominal or chest thrusts carry significant potential for injury, including:
   • Rib fractures or cartilage damage.
   • Internal injuries to abdominal organs such as the liver, spleen, or stomach.
   • Soreness or muscle strain in the area of compression.
   • Damage to the larynx or throat from the object itself.
3. Retrieval of Object: If the obstruction was removed by the rescuer, note the type and size of the object, as this information is relevant for medical staff.

Conclusion

Abdominal thrusts are a high-stakes, high-impact intervention critical for managing foreign body airway obstruction in conscious adults. Success relies on rapid recognition, precise anatomical placement, and the delivery of forceful, distinct compressions in an inward and upward direction. Rescuers must be trained not only in the standard five-and-five cycle but also in the modifications necessary for pregnant and obese victims. Due to the inherent risk of internal injury associated with the required force, professional medical follow-up is indispensable following any successful intervention.

References

1. American Heart Association (AHA). (2020). Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 5 – First Aid. Circulation.
2. American Red Cross. (2021). First Aid/CPR/AED Participant’s Guide. American Red Cross.
3. Handley, A. J., Koster, R., Monsieurs, K., Perkins, G., Davies, S., & Bossaert, L. (2005). European Resuscitation Council guidelines for resuscitation 2005. Section 2. Adult life support and automated external defibrillation. Resuscitation, 67 (Suppl 1), S7–S21.
4. Hovig, M. R., Svane, M. S., & Oskarsdóttir, Á. (2018). Foreign body aspiration in adults: epidemiology and outcomes. International Journal of Environmental Research and Public Health, 15(11), 2419.
5. National Academies of Sciences, Engineering, and Medicine (NASEM). (2017). A Conceptual Framework for the Development of First Aid Instructional Guidelines. National Academies Press.