Editing Choking (section)

===Particular cases===

==== Infants (babies under 1 year-old) ====
The majority of choking injuries and fatalities occurs in children aged 0–4,<ref>{{Cite journal |last1=Chang |first1=David T. |last2=Abdo |first2=Kaitlyn |last3=Bhatt |first3=Jay M. |last4=Huoh |first4=Kevin C. |last5=Pham |first5=Nguyen S. |last6=Ahuja |first6=Gurpreet S. |date=May 2021 |title=Persistence of choking injuries in children |url=https://linkinghub.elsevier.com/retrieve/pii/S0165587621000781 |journal=International Journal of Pediatric Otorhinolaryngology |language=en |volume=144 |pages=110685 |doi=10.1016/j.ijporl.2021.110685|pmid=33819896 |s2cid=233036815 }}</ref> highlighting the importance for widespread dissemination of the appropriate anti-choking techniques for these age groups. In fact, it has been shown that increased parental education may decrease choking rates among children.<ref>{{Cite journal |last1=Bentivegna |first1=Kathryn C. |last2=Borrup |first2=Kevin T. |last3=Clough |first3=Meghan E. |last4=Schoem |first4=Scott R. |date=October 2018 |title=Basic choking education to improve parental knowledge |url=https://linkinghub.elsevier.com/retrieve/pii/S0165587618303823 |journal=International Journal of Pediatric Otorhinolaryngology |language=en |volume=113 |pages=234–239 |doi=10.1016/j.ijporl.2018.08.002|pmid=30173993 |s2cid=52145517 }}</ref>

For infants under 1 year-old, the American Heart Association recommends adapted procedures.<ref>{{Cite journal |last=Wilkins, Lippincott Williams |date=2010-11-02 |title=Editorial Board |journal=Circulation |volume=122 |issue=18_suppl_3 |pages=S639 |doi=10.1161/CIR.0b013e3181fdf7aa|doi-access=free }}</ref> The size of the children's body is the most important aspect in determining the correct anti-choking technique. So the [[Choking#techniques in the first aid protocol against choking|normal first aid techniques against choking]] would be tried in children who are too large for the babies' procedures (or they would be tried as a less appropriated attempt if the rescuer is unable to perform the techniques for babies).

First aid for choking infants alternates a cycle of special back blows (five back slaps) followed by special chest thrusts (five adapted chest compressions). [[File:Heimlich Infant.png|thumb|'''Left:''' 'Back blows for infants', the baby receives the slaps being carefully held and slightly placed upside-down; a support under the chest is recommended.
----'''Right:''' 'Chest thrusts for infants', two fingers press on the lower half of the middle of the chest.|alt=|400x400px]]In the ''back blows maneuver'', the rescuer slaps on the baby's back. It is recommended that the baby receive them being slightly leaned upside-down on an inclination. There exist several ways to achieve this:

According to a widely propagated modality: the rescuer sits down on a seat with the baby, and supports the baby with a forearm and its respective hand. The baby's head must be carefully held with that hand (approximately by the face), and kept in a normal position, facing forward, not inclinated. Then the baby's body can be leaned forward upside-down along the rescuer's thighs, and receive the slaps.

As an easier alternative: the rescuer can sit on a bed or sofa, or even the floor, carrying the baby. Next, the rescuer should support the baby's body on the own lap, to lean the baby a bit upside-down at the right or the left of the lap. The baby's head must be in a normal position, facing forward, frontally, and not inclinated. It is always convenient that the baby's chest is supported against something. Then the rescuer would slap the back of the baby.

If the rescuer cannot sit down: at least it is possible to attempt the manoeuver at a low height and over a soft surface. Then the rescuer would support the baby with a forearm and the hand of that side, holding carefully the baby's head with that hand (approximately by the face, but always trying that the baby's head keeps in a normal position, facing forward, not inclinated). The baby's body would be leaned upside-down in that position to receive the slaps. In situations with rescuers who cannot do all of that (as rescuers with disabilities and others), they can still try the normal back blows, supporting the baby's chest with one hand, bending the baby's body, and then giving firm slaps with the other hand.

In the ''chest thrusts manoeuver'', the baby's body is placed lying face up on a surface (it can be the rescuer's thighs, lap or forearm). Then, the rescuer does the compressions pressing with only two fingers on the lower half of the bone that is along the middle of the chest from the neck to the belly (on the chest bone, named [[sternum]], on its part that is the nearest to the belly). Abdominal thrusts are not recommended in children less than one year old because they can cause liver damage.<ref name=":4">{{Cite journal |last=Wilkins |first=Lippincott Williams & |date=2010-11-02 |title=Editorial Board |journal=Circulation |language=en |volume=122 |issue=18 suppl 3 |pages=S639 |doi=10.1161/CIR.0b013e3181fdf7aa |issn=0009-7322 |doi-access=free}}</ref>

The back blows and chest thrusts are ''alternated in cycles'' of five back blows and five chest compressions until the object comes out of the infant's airway or until the infant becomes unconscious.<ref name=":4" />

If choking is unresolved despite these rescue attempts, it is vital that somebody calls to the [[List of emergency telephone numbers|emergency medical services]] and continue first aid until they arrive. An infant can fall unconscious soon, then an anti-choking resuscitation for infants is required (read next).

===== Unconscious infants =====
An ''unconscious'' infant has to be placed face-up on a firm and horizontal surface (as the floor). The baby's head must be in a straight position, facing frontally, because tilting it too much backwards can close the access to the trachea in infants.

A rescuer can then ask for any of the known anti-choking devices, and try it on the unconscious baby. There can be difficulties because of the little size of the infant. The obstruction can be dislodged, but remaining into the mouth, which would need a manual removal. If the baby cannot breath then, or stays in a cardiac arrest, the rescuer must perform a normal cardiopulmonary resuscitation (CPR), as it is described below, but only alternating the 30 compressions and the 2 rescue breaths.

[[List of emergency telephone numbers|Emergency medical services]] must be called, if this has not been done yet.

It can be also convenient that any rescuer asks for a defibrillator near (an AED, as those devices are very common today), just in case it is necessary to treat the baby's heart.

Until emergency services arrive, the American Heart Association<ref name=":4" /> recommends starting (even<ref name=":9" /><ref name=":11" /> with no more delay) an anti-choking cardiopulmonary resuscitation (CPR) adaptive to infants less than one year old (described below). It is a cycle of resuscitation<ref>{{Cite book |last=American Red Cross |title=CPR/AED and First Aid |pages=33 |chapter=Choking – Special Situations}}</ref> that alternates compressions and rescue breaths, like in a normal CPR, but with some differences: 
The rescuer begins by making 30 ''compressions,'' pressing with only two fingers on the lower half of the bone that crosses the middle of the chest from the neck to the belly (on the chest bone, named [[sternum]], on its part that is the nearest to the belly), at an approximate rhythm of nearly 2 per second.

At the end of the round of compressions, the rescuer looks into the mouth for the obstructing object. And, if it is already visible, the rescuer makes a ''try to extract it'' (usually using a finger sweep). The rescuer must not confuse a foreign object with the epiglottis: a cartilaginous flap of the throat. It is possible to try to extract the object without seeing it, always carefully: taking it with the fingers, or using a toothpick (maybe, because almost any other tool would be too wide for a baby), but the current protocols do not recommend extracting the object if it is not visible (a blind extraction), because of the risk to sink it deeper by accident, and because the compressions could move the object outside by themselves (in some cases). A rescuer that already knows that the choking object is a bag (or similar) does not need to see the object before trying to extract it (because there is no risk of sinking it much deeper, and it is easy to detect by using the touch carefully). Anyway, if any removal is tried and takes too much time, it may require alternating it with the chest compressions at some moments, without hindering to the extraction. And, being the object extracted or not in this step, this CPR procedure must pass to the next action and continue until the babies can breathe by themselves or emergency medical services arrive.

In the next step of the CPR, the rescuer makes ''a rescue breath'', covering the baby's mouth and nose simultaneously with the own mouth, and puffing air inside a first time. After that first rescue breath, it is recommended ''tilting the baby's head'' up and down, trying to open a space for the air in that manner, but leaving it approximately straight again, and then giving ''an additional rescue breath'', for the second time''.'' The rescue breaths usually fail while the object is still blocking, but then the rescuer has only to continue with the next step. Anyway, they can enter and reach the lungs, and then the chest of the baby would be seen rising. If a rescue breath arrived there, it is because the object has been moved to an unknown position that leaves some open space, so it can be useful making the next rescue breaths more softly to avoid moving the object to a new blocking position again, and, in case of those soft rescue breaths are not successful, increasing the strength of blowing in the next ones. The bodies of the babies are delicate, and, when the airway is not clogged, only a little strength in blowing is enough to fill their lungs. The baby's colour would improve after some successful rescue breaths. After the rescue breaths, the rescuer has to return to the 30 initial compressions, repeating the same resuscitation cycle again, continually, until the choking baby regains consciousness and breathe normally, or until the object is extracted but a defibrillation is needed to solve a cardiac arrest (read below).

''Defibrillation'' can also be needed, because a choking infant that is already unconscious can suffer a cardiac arrest at any moment, due to several possible causes.<ref name=":13" /> So it is convenient to ask around for a defibrillator (AED device), for trying a defibrillation on a baby that remains in cardiac arrest after having extracted the stuck object (only if the object has been extracted). Those defibrillators are easy to use, as they emit their instructions with voice messages. One of the pads of the defribrillator (any of them) is attached to the baby's chest, and the other pad to the baby's back.

==== Pregnant or obese people ====
Some choking victims cannot receive pressure on their bellies. Then, the American Heart Associated recommends<ref name=":2" /> substituting the abdominal thrusts for chest thrusts.

These victims can include: patients with serious injuries in the abdomen, pregnant women, and obese patients; however, in the case of the obese victims, if the rescuer is capable enough to effectively wrap their arms around the circumference of the victim's abdomen, it is possible to apply the normal first aid against choking, with abdominal thrusts (see details further above).

Chest thrusts are performed in a similar way to the abdominal thrusts, but with the fist placed on the lower half of the vertical bone that is along the middle of the chest (the chest bone, named [[sternum]]), rather than on the abdomen. As a reference, in women, the zone of pressure of the chest thrusts would be normally higher than the breasts. It is convenient to avoid placing the knuckles too painfully. Finally, strong inward thrusts are then applied.<ref name="Choking: First aid" />

The rest of the first aid protocol is the same, starting with asking the victim to cough freely, and then, if the victim cannot cough, the series of chest thrust are alternated with series of slaps on the back. Those back slaps are applied normally: bending forward the back of the victims and supporting their chest with one hand.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

When the victims with abdominal problems become unconscious, they need the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is employed for other unconscious choking victims (see details further above).

Preventively, if a person with abdominal problems (as injury, pregnancy, or too much obesity) is present, placing an [[#Anti-choking devices|anti-choking device]] nearby can be useful.

====In wheelchair-using victims====
If the choking victim is a wheelchair-using person, the procedure is similar to how it is for other victims. The main difference is in trying to apply the techniques directly, while the victim is using the wheelchair.<ref name=":7">{{Cite web |title=Choking Awareness, wheelchair user |url=http://helpstopchoking.hscni.net/uploaded/files/1/2015/04/1093-Choking_Awareness_App_wheelchair_user.pdf |website=Belfast Health and Social Care Trust |access-date=2023-11-30 |archive-date=2020-07-15 |archive-url=https://web.archive.org/web/20200715195214/http://helpstopchoking.hscni.net/uploaded/files/1/2015/04/1093-Choking_Awareness_App_wheelchair_user.pdf |url-status=bot: unknown }}</ref>

''Coughing'' should be encouraged first before applying the techniques. When the victim cannot cough, it is recommended alternating series of back blows and thrusts, as in other cases.<ref name=":5"/><ref name=":7"/>

''Back blows'' (back slaps) can be used after substantially bending forward the back of the victim, and supporting the victim's chest with the other hand.

''Abdominal and chest thrusts'' can also be used. To perform the abdominal thrusts, the rescuer must get behind the wheelchair. Then, the rescuer can embrace the victim's abdomen from behind and above, leaning over the top of the wheelchair's backrest. If this is too difficult, the rescuer can get down and embrace from behind the victim's abdomen and the wheelchair's backrest all together. In narrow spaces that cannot be opened, the position can be achieved by turning the victim to one side. Finally, the rescuer would grasp the own hand with the other, place them between the chest and the belly button of the victim, and apply sudden pressures with them on that zone, in a direction of in-and-up. If the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), chest thrusts must be used instead. They are applied while the victim is using the wheelchair too, but making sudden inward pressures on the lower half of the breast bone ([[sternum]]), which is placed vertically along the middle of the chest. If the space is too narrow and impossible to widen, the abdominal or chest thrusts can be tried by turning the victim to one side.

Rescuers should ''alternate between back slaps and chest thrusts repeatedly'' until the choking is solved, as in other victims.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

If a wheelchair-using victim of choking becomes ''unconscious'', anti-choking cardiopulmonary resuscitation (CPR) should be performed, which is the same method also used for able-bodied victims of choking. That said, it can be noted that the victim needs to be removed from the wheelchair and laid face-up on an appropriated surface (not too hard or too soft, and it is possible to put a layer of something between the floor and the victim). While they are on their way, the rescuer should apply [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] for unconscious victims (see details further above).

As a ''preventive'' measure, it is convenient to avoid placing patients with disabilities in a narrow and encased spaces at mealtimes, as more open spaces allow easier access for rescuers. Besides, placing an [[#Anti-choking devices|anti-choking device]] nearby is a common safety measure in environments.

==== On the bed but unable to sit up ====
If the choking victim is lying in bed, but is conscious and unable to sit up (such as in patients with disabilities or injuries), ''the first aid would be the same, but performed by sitting the patient on the edge of the bed.''

Before adjusting the patient's position, the rescuer encourages the victim to cough freely and as forcefully as they can manage. The victim would do it better by turning to one side. When coughing is too difficult or impossible, the rescuer would sit the victim on the bed's edge, to make coughing easier or to apply the anti-choking manoeuvers (these are required if the victim cannot cough).

This can be achieved<ref>{{Cite web |date=2018-12-22 |title=Assisting a Patient to a Sitting Position and Ambulation |url=https://med.libretexts.org/Bookshelves/Nursing/Book%3A_Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/03%3A_Safe_Patient_Handling_Positioning_and_Transfers/3.06%3A_Assisting_a_Patient_to_a_Sitting_Position_and_Ambulation |url-status=live |archive-url=https://web.archive.org/web/20211007124333/https://med.libretexts.org/Bookshelves/Nursing/Book:_Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/03:_Safe_Patient_Handling_Positioning_and_Transfers/3.06:_Assisting_a_Patient_to_a_Sitting_Position_and_Ambulation |archive-date=2021-10-07 |access-date=2021-11-07 |website=Medicine LibreTexts |language=en}}</ref> grasping the victim by the legs (behind of the knees, or by the calves or ankles) and rotating them until they are out of the bed. Next, the rescuer would sit the victim up on the edge, pulling the shoulders or arms (in the forearms or wrists). Then it is possible to apply the anti-choking manoeuvers<ref name=":5" /> from behind: series of back slaps (after leaning the victim forward, and supporting the chest with one hand) and series of abdominal thrusts (sudden compressions on the part of the victim's belly that is between the chest and the belly button, in a direction of in-and-up). When the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), the rescuer needs to change them for chest thrusts (sudden pressures inward on the lower half of the [[Sternum|breast bone]], which is placed vertically along the middle of the chest, from the neck to the belly).

When a rescuer cannot sit the victim up, it is possible to perform chest or abdominal thrusts frontally while the victim is lying on the bed (despite they would be less effective in that horizontal position). They are made by putting one hand on the top of the other and making with both of them strong pressures downwards on the lower half of the breast bone (the [[sternum]]), or in a downward-and-frontward direction between the chest and the belly button.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

When the victims of choking in bed become unconscious, they need the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is employed for other unconscious choking victims (see details further above).

''Preventively'', it is important to know that eating while laying in bed increases the risk of choking. When a person with a disability or injury is present, a common measure of prevention is placing an [[#Anti-choking devices|anti-choking device]] at reach.

==== On the floor but unable to sit up ====
It is possible, though rare, that a choking victim would be laying on the floor but conscious. For example, someone having a disability that makes impossible to sit up and to keep standing up on the feet. If this is the case, ''the first aid is'' ''the same, but after sitting the victim on the floor''.

Before adjusting the patient's position, the rescuer asks the victim to cough freely and with strength. The victim would cough better by turning to a side. If coughing is too difficult or impossible, the rescuer would sit the victim up, to make it easier or to apply anti-choking maneuvers (these are needed when the victim cannot cough).

A rescuer would sit the victim up by pulling the shoulders or arms (in the forearms or wrists). When the victim is sitting up, the rescuer can sit behind to apply the anti-choking manoeuvers: back slaps (after bending very much the back of the victim, and supporting the chest with one hand) and abdominal thrusts (sudden compressions in a direction of in-and-up, on the part of the victim's belly that is between the chest and the belly button). When victims cannot receive abdominal thrusts properly (as the seriously injured in the belly, and the pregnant women), the rescuer needs to change them for chest thrusts (sudden pressures inward on the lower half of the [[Sternum|breast bone]], which is placed vertically along the middle of the chest, from the neck to the belly).

In some situations it is impossible to sit the victim up, and then the rescuer can try one of the thrusts techniques to the front of their abdomen and chest (even though this is less effective, it could be the only option and therefore worth a try). Anyway, they can be made by putting one hand on the top of the other and using them to make strong pressures downwards on the lower half of the breast bone (the [[sternum]]), or downwards-and-frontwards on the abdomen (between the chest and the belly button).

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

If the victim is unconscious, it is needed the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is used in other unconscious choking victims (see details further above).

In the ''prevention'' of choking, it can be remembered the practice of placing an [[#Anti-choking devices|anti-choking device]] around people with disabilities.

==== Seizing victim ====
Seizing can occur for a multitude of reasons, but is common in those diagnosed with epilepsy. During a seizure, victims may experience strangulation or throat constriction during consciousness.<ref>{{Cite journal |last=Nimeshan |first=Geevasinga |date=2000-12-08 |title=Choking, Asphyxiation, and the Insular Seizure |url=http://dx.doi.org/10.1054/jocn.1999.0776 |journal=Journal of Clinical Neuroscience |pages=1–16 |doi=10.1054/jocn.1999.0776 |doi-broken-date=1 November 2024 |issn=0967-5868}}</ref> The victim will not have control of their bodily functions and will need someone to create a safe area for them. One should clear a space where the victim can lay down and remove or loosen anything that is around their neck. Then one should turn them on their side as to help them breathe and to avoid potential choking on the saliva.<ref>{{Cite web |date=2020-09-30 |title=Seizure First Aid {{!}} Epilepsy {{!}} CDC |url=https://www.cdc.gov/epilepsy/about/first-aid.htm |access-date=2021-12-08 |website=www.cdc.gov |language=en-us}}</ref>