Editing Choking (section)

=== Basic treatment (first aid) ===
[[File:US medic teaches the Heimlich manuever to laughing Afghans.jpg|thumbnail|right|US medic teaches the [[abdominal thrusts]] to Afghans]]Basic treatment of choking includes several non-invasive techniques to help remove foreign bodies from the airways.

==== General strategy: "five and five" ====
For a conscious choking victim,<ref name=":5">{{Cite web |title=Conscious Choking |url=https://redcross.org/content/dam/redcross/atg/PDF_s/ConsciousChokingPoster_EN.pdf |url-status=live |archive-url=https://web.archive.org/web/20200131092855/https://redcross.org/content/dam/redcross/atg/PDF_s/ConsciousChokingPoster_EN.pdf |archive-date=2020-01-31 |website=American Red Cross}}</ref> most institutions such as the American Heart Association, the American Red Cross and the NHS,<ref>{{cite web | url=https://www.nhs.uk/conditions/first-aid/ | title=First aid | date=24 October 2017 }}</ref> recommend the same general protocol of first-aid: encouraging the victim to cough, followed by hard back slaps (as described forward). If these attempts are not effective, the procedure continues with abdominal thrusts (the Heimlich maneuver) or chest thrusts if the victim cannot receive abdominal pressure (as described forward).

If none of these techniques are effective, protocol by various institutions recommend alternating the series of back slaps and series of thrusts (these on the abdomen or chest, depending on the victim), 5 times of each technique and repeat ("five and five"). Some anti-choking devices can also be used to solve choking.

This procedure has modifications for [[#Infants (babies under 1 year-old)|infants (babies under 1 year-old)]], for the [[Choking#Pregnant or obese people|people with problems in the belly as the pregnant or too much obese people]], for the [[#In wheelchair victims|disabled victims in wheelchair]], for the [[#On the bed but unable to sit up|victims that lay on the bed but are unable to sit up]], and for the [[#On the floor but unable to sit up|victims that lay on the floor but are unable to sit up]].

In scenarios when the first aid procedures are not resolving the choking, it is necessary to call to [[List of emergency telephone numbers|emergency medical services]], but administration of first aid should be continued until they arrive.

Choking can change the colour in the victim's faces due to lack of oxygen. If they lose consciousness and fall to the ground, it is recommended<ref name=":2">{{cite web |title=Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality – ECC Guidelines |url=https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/?strue=1&id=10-5 |access-date=4 December 2017 |website=eccguidelines.heart.org}}</ref><ref name="redcross.org">{{cite web |title=STEP 3: Be Informed – Conscious Choking {{!}} Be Red Cross Ready |url=https://redcross.org/flash/brr/English-html/conscious-choking.asp |archive-url=https://web.archive.org/web/20171205094624/https://redcross.org/flash/brr/English-html/conscious-choking.asp |archive-date=2017-12-05 |access-date=4 December 2017 |website=redcross.org}}</ref> to avoid panic and begin the appropriate [[#Unconscious victims|anti-choking resuscitation for unconscious victims]] or [[#Unconscious infants|unconscious babies (under 1 year-old)]].

Each one of the techniques in the first aid protocol against choking are detailed below:{{Anchor|techniques in the first aid protocol against choking}}

==== Cough ====
If the choking victim is conscious and can cough, the [[American Red Cross]] and the [[Mayo Clinic]]<ref name="Choking: First aid">{{cite web |last=Mayo Clinic |title=Choking: First aid |url=http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |url-status=live |archive-url=https://web.archive.org/web/20170501045204/http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |archive-date=1 May 2017 |access-date=1 Jul 2024 |website= |publisher=Mayo Foundation for Medical Education and Research (MFMER) |language=en}}</ref> recommend encouraging them to stay calm and continue coughing freely.

==== Back blows (back slaps) ====
Many associations, including the American Red Cross and the Mayo Clinic,<ref name="Choking: First aid" /><ref name=":5" /> recommend the use of back blows (back slaps) to aid a choking victim. This technique is performed by bending the choking victim forward as much as possible, even trying to place their head lower than the chest, to avoid the blows driving the object deeper into the person's throat (a rare complication, but possible). The bending is in the back, while the neck should not be excessively bent. It is convenient that one hand supports the victim's chest. Then the back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades.

The back slaps push behind the blockage to expel the foreign object out. In some cases, the physical vibration of the action may cause enough movement to clear the airway.

==== Abdominal thrusts (Heimlich maneuver) ====
{{See also|Abdominal thrusts}}[[File:Abdominal thrusts against choking.jpg|thumb|380x380px|Abdominal thrusts anti-choking technique: Embrace the victim's abdomen from behind and then apply strong compressions on the area located between the chest and the belly button.]]
Abdominal thrusts<ref>{{Cite web |title=First Aid Tips |url=https://redcross.org.uk/standard.asp?id=75052 |url-status=live |archive-url=https://web.archive.org/web/20090203134643/https://redcross.org.uk/standard.asp?id=75052 |archive-date=2009-02-03 |website=Red Cross}}</ref> are performed with the rescuer embracing the belly of the choking victim from behind. Then, the rescuer closes their own dominant hand, grasps it with the other hand, and presses forcefully with them on the area located between the chest and the belly button of the victim, in a direction of in-and-up. This method tries to create enough pressure upwards to expel the object that obstructs the airway. The strength is not focused directly against the ribs, to avoid breaking them. If the first thrust does not solve the choking, it can be repeated several times.

The use of abdominal thrusts is not recommended for infants under 1 year of age due to risk of causing injury, so there are adaptations for babies (see more details further below), but a child that is too big for the babies' adaptations would require normal abdominal thrusts (according to the size of the body). Besides, abdominal thrusts should not be used when the victim's abdomen presents problems to receive them, such as pregnancy or excessive size; in these cases, chest thrusts are advised (see more details further below).

Although it is a well known method for choking intervention, the Heimlich Maneuver is backed by limited evidence and unclear guidelines. The use of the maneuver has saved many lives but can produce deleterious consequences if not performed correctly. This includes rib fracture, perforation of the jejunum, diaphragmatic herniation, among others.<ref>{{Cite journal |last1=Fearing |first1=Nicole M. |last2=Harrison |first2=Paul B. |date=2002-11-02 |title=Complications of the Heimlich Maneuver: Case Report and Literature Review |url=http://dx.doi.org/10.1097/00005373-200211000-00026 |journal=The Journal of Trauma: Injury, Infection, and Critical Care |volume=53 |issue=5 |pages=978–979 |doi=10.1097/00005373-200211000-00026 |issn=0022-5282 |pmid=12435952}}</ref>

==== Chest thrusts ====
[[File:Chest thrusts against choking.jpg|thumb|380x380px|Chest thrusts anti-choking technique: If the victim cannot receive thrusts on the abdomen, use chest thrusts. Embrace the victim's chest from behind and then apply strong compressions on the lower half of the chest bone, but not in the very endpoint. Avoid sticking the knuckles too painfully.]]When abdominal thrusts cannot be performed on the victim (serious injuries, pregnancy, or belly size that is too large for the rescuer to effectively perform abdominal thrust technique), chest thrusts are advised instead.<ref>{{Cite web |title=Choking and CPR safety talk |url=https://ehs.okstate.edu/site-files/docs/cpr-and-choking-5-min-safety-talk.pdf/ |url-status=live |archive-url=https://web.archive.org/web/20200130145512/https://ehs.okstate.edu/site-files/docs/cpr-and-choking-5-min-safety-talk.pdf/ |archive-date=2020-01-30 |website=Oklahoma State University}}</ref>

Chest thrusts are performed with the rescuer embracing the chest of the choking victim from behind. Then, the rescuer closes the own dominant hand and grasps it with the other hand. This can produce several kinds of fists, but any of them can be valid if it can be placed on the victim's chest without sinking a knuckle too painfully. Keeping the fist with both hands, the rescuer uses it to press forcefully inwards on the lower half of the chest bone ([[sternum]]). The pressure is not focused on the very endpoint (named [[xiphoid process]]) to avoid breaking it. When the victim is a woman, the zone of the pressure of the chest thrusts would normally be above the level of the breasts. If the first thrust does not solve the choking, it can be repeated several times.

==== Anti-choking devices ====<!--Note, there are redirects to this section name-->
Since 2015, several anti-choking devices were developed and released to the market. They are based on a mechanical vacuum effect, without a power source. Most use an attached mask to make a [[Vacuum pump|vacuum]] from the patient's nose and mouth. The current models of anti-choking devices are quite similar: a direct plunger tool (LifeVac and Willnice)<ref>{{Cite web |date=2016-08-02 |title=How to use LifeVac |url=https://lifevac.life/how-to-use-lifevac/ |access-date=2020-01-20 |website=Lifevac.life |language=en-US}}</ref><ref>{{Cite web |title=[OFFICIAL] Willnice {{!}} Anti-Choking Device that Saves Lives |url=https://willnice.net/ |access-date=2024-10-20 |website=Willnice |language=en-US}}</ref>  and a vacuum syringe (backward syringe) that also keeps the tongue in place by inserting a tube in the mouth (Dechoker).<ref>{{Cite web |last=Dechoker |title=How to Use Dechoker Anti-Choking Device (ACD) |url=https://www.dechoker.com/pages/dechoker-usage-instructions |access-date=2020-01-20 |website=Dechoker |language=en |archive-date=2019-06-05 |archive-url=https://web.archive.org/web/20190605154838/https://www.dechoker.com/pages/dechoker-usage-instructions |url-status=dead }}</ref> All  three of them have received certification, and they have been reported to be effective in real cases.<ref>{{Cite web |date=2019-02-03 |title=Advocates say anti-choking device saved two lives in Idaho {{!}} Local {{!}} idahostatejournal.com |url=https://idahostatejournal.com/news/local/advocates-say-anti-choking-device-saved-two-lives-in-idaho/article_4a24cfab-3261-5083-b73c-c6629cc2c790.html |archive-url=https://web.archive.org/web/20190203001109/https://idahostatejournal.com/news/local/advocates-say-anti-choking-device-saved-two-lives-in-idaho/article_4a24cfab-3261-5083-b73c-c6629cc2c790.html |archive-date=2019-02-03 |access-date=2021-09-25}}</ref><ref>{{Cite web |title=Carers used suction device to save woman who choked on sausage |url=https://www.kidderminstershuttle.co.uk/news/17821998.carers-used-dechoker-save-woman-choked-sausage/ |access-date=2021-09-25 |website=Kidderminster Shuttle |date=7 August 2019 |language=en}}</ref> Other mechanical models are in development, such as Lifewand,<ref>{{Cite web |title=The Device |url=https://lifewand.com/ |archive-url=https://web.archive.org/web/20220312021951/https://lifewand.com/ |archive-date=12 March 2022 |website=Lifewand}}</ref> which creates a vacuum by direct pressure against the patient's face. However, these products have not been well-studied in clinical trials or pre-hospital settings and literature is relatively sparse given the challenges in trial design.
<!--These claims are unsourced, and possibly "original research". Could be reinstated if reliably sourced.
The use of approved devices can provide some advantages including: ease of use, convenience in public places and events, being helpful for difficult cases (unconscious victims, disabled patients, elderly people, or when the victim is oneself), and achieving levels of pressure in suction that cannot be matched by manual methods. ''In the worst choking cases, no manual technique would dislodge the foreign object, being necessary the usage of one of these devices or a sort of surgery.'' These devices are usually placed at reach in public and relevant places.-->

A 2020 systematic review of the effectiveness of the three devices listed discovered "a more detailed review of the studies demonstrated a very low certainty of evidence for its use", and concluded that "there are many weaknesses in the available data and few unbiased trials that test the effectiveness of anti-choking suction devices resulting in insufficient evidence to support or discourage their use. Practitioners should continue to adhere to guidelines authored by local resuscitation authorities which align with [[International Liaison Committee on Resuscitation|ILCOR]] recommendations."<ref>{{Cite journal |last=Dunne |first=Cody |year=2020 |title=A systematic review on the effectiveness of anti-choking suction devices and identification of research gaps |url=https://www.resuscitationjournal.com/article/S0300-9572(20)30087-3/fulltext |journal=Resuscitation |volume=153 |pages=219–226 |doi=10.1016/j.resuscitation.2020.02.021 |pmid=32114068 |s2cid=211725361|hdl=1959.4/unsworks_79490 |hdl-access=free }} [https://www.researchgate.net/publication/339541654_A_systematic_review_on_the_effectiveness_of_anti-choking_suction_devices_and_identification_of_research_gaps Downloadable draft.]</ref>

As of October 22, 2024, The American Red Cross has updated its guidelines to include antichoking devices which highlighted the LifeVac for its effectiveness in clearing the airway passages. The scientific analyses of the LifeVac revealed a dislodgement rate of 94% during the first attempt, 99.6% on the second attempt, and a 100% success rate on the third attempt. There has so far been no known side effects due to the LifeVac device according to these studies. According to the findings, the evaluation on PubMed records from September 2019 through March 2023 which identified nearly 4,000 documents relating to the study which was significantly lead by the document "LifeVac: A Novel Apparatus to Resuscitate a Choking Victim" which were evaluated by the Journal of the American Red Cross Scientific Advisory Council (American Red Cross).

Some anti-choking devices like [[Act Fast Anti Choking Trainer]] are used as training devices by healthcare providers as well as schools in CPR training courses.<ref>{{Cite web |title=The Actfast Anti-Choking Trainer {{!}} PDF {{!}} Survival Skills {{!}} First Aid |url=https://www.scribd.com/document/358181502/The-Actfast-Anti-Choking-Trainer |access-date=2024-02-02 |website=Scribd |language=en}}</ref>

==== Unconscious victims ====

A choking victim who becomes unconscious<ref name=":22" /><ref>{{Cite web |last=Mayo Foundation for Medical Education and Research (MFMER) |date=2024-05-31 |title=Choking: First aid |url=http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |access-date=2024-07-01 |website=Mayo Clinic|archive-url=https://web.archive.org/web/20240531120521/http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |archive-date=2024-05-31 }}</ref><ref>{{Cite book |last=American Red Cross |title=CPR/AED and First Aid |pages=22 |chapter=Unconscious Choking}}</ref> must be gently caught before falling and placed lying face-up on a surface.<ref><!--useless ref?-->{{Cite journal |last=Herbert |first=Henry |year=1981 |title=Book review: The American Medical Association's Handbook of First Aid and Emergency Care |url=http://dx.doi.org/10.1097/00043764-198102000-00004 |journal=Journal of Occupational and Environmental Medicine |volume=23 |issue=2 |pages=74 |doi=10.1097/00043764-198102000-00004 |issn=1076-2752}}</ref> That surface should be firm enough (it is recommended placing a layer of something on the floor and laying the victim above).

A rescuer can then ask for any of the known anti-choking devices that is available, and use it on the unconscious victim. After that, the obstruction would be dislodged, but it could remain into the mouth, which needs a manual removal. If the unconscious victim cannot breath then, or stays in a cardiac arrest, it will require to perform a normal cardiopulmonary resuscitation (CPR), as described below, but only alternating the 30 compressions and the two rescue breaths.

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

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

Anyway, a choking victim that is already unconscious needs to receive (even<ref name=":9">{{Cite web |last=Sarver Heart Center. University of Arizona. |date=2024-01-27 |title=Frequently Asked Questions about CPR |url=https://heart.arizona.edu/heart-health/learn-cpr/frequently-asked-questions-about-chest-compression-only-cpr |access-date=2024-07-03 |website=heart.arizona.edu|archive-url=https://web.archive.org/web/20240127072004/https://heart.arizona.edu/heart-health/learn-cpr/frequently-asked-questions-about-chest-compression-only-cpr |archive-date=2024-01-27 }}</ref><ref name=":11">{{Cite web |last=American Heart Association |title=Guidelines for CPR and ECC |url=https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf?la=en |page=12|archive-url=https://web.archive.org/web/20211220204935/https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf?la=en |archive-date=2021-12-20 }}</ref> with no more delay) an anti-choking cardiopulmonary resuscitation (CPR) for unconscious adults and children. It is not valid for infants less than one year old, who require a special [[#Unconscious infants|adaptated CPR for unconscious babies]] (described further below). [[File:Chest compressions.gif|thumb|Chest compressions of cardiopulmonary resuscitation (CPR), proper rhythm.|250x250px]]

The anti-choking cardiopulmonary resuscitation (CPR) for unconscious adults and children is quite similar to any other CPR, but with some modifications:

In a first step, a series of 30 ''chest'' ''compressions'' are applied on the lower half of the [[sternum]] (the bone that is along the middle of the chest from the neck to the belly) at an approximate rhythm of nearly 2 per second.

After that series, the rescuer looks for the obstructing object and, if it is already visible, the rescuer makes a ''try to extract'' it, usually by using a finger sweeping (hopefully from the mouth). Normally, the object would be a food bolus (and not the epiglottis, a cartilaginous flap of the throat). It is also possible to try to extract it when it is deeper and not visible, always carefully: using the fingers to take it, or lifting the victim's chin to form a straight way to the throat while the victim is face up (face down in case of the victim's tongue obstructs too much, or on a side with a base under the head) and then grasping or sweeping the stuck object with tools: thin kitchen tweezers, scissors (these used with care), forks and spoons (in a reverse position: introducing their handle) or even a toothpick (if other instruments were too much big for the case); but, anyway, the current protocols do not recommend extracting the obstructing 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). Moreover, if any removal is tried and is taking too much time, it may require alternating it with the chest compressions at some moments, without hindering to the extraction. And, whether the object has been found and removed in this step or not, the CPR procedure must pass to the next step and continue until the victims can breathe by themselves or emergency medical services arrive.[[File:Insulfation2.jpg|thumb|Rescue breaths of cardiopulmonary resuscitation (CPR).|250x250px]]

In the next step of the CPR, the rescuer applies ''a'' ''rescue breath'', pinching the victim's nose and puffing air inside of the mouth. Rescue breaths would usually fail while the obstructing object is blocking the entrance of air. Anyway, it is recommended, additionally, ''tilting the victim's head'' up and down, to reposition it trying to open an entrance for the air, and then giving ''another rescue breath''. After the rescue breaths, this resuscitation returns to the 30 initial compressions, in a cycle that repeats continually, until the victim regains consciousness and breathes,<ref>American Red Cross Training Services. Choking. In: First Aid/CPR/AED Participant's Manual. The American Red Cross; 2021. https://www.redcross.org/store/first-aid-cpr-aed-participants-manual/754100.html .</ref> or until the object is extracted but a defibrillation is needed to solve a cardiac arrest (read below).

''Defibrillation'' can also be needed, because an unconscious victim of choking can suffer a cardiac arrest at any moment, due to several possible causes.<ref name=":13">{{Cite web |date=2024-07-03 |title=First aid - To perform CPR on a baby 4 weeks old, or older - such as from choking - get the AED |url=http://mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 |access-date=2024-07-04 |website=Mayo Clinic|archive-url=https://web.archive.org/web/20240703122615/http://mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 |archive-date=2024-07-03 }}</ref> So it is convenient to ask around for a defibrillator (AED device), for trying a defibrillation on a victim that remains in cardiac arrest after having extracted the stuck object (if it has been extracted, and only after that). Those defibrillators are easy to use, as they emit their instructions with voice messages.

===== Finger sweeping =====
It is crucial to avoid blindingly sweeping the airway unless there is direct visualization of the airway – in fact, these procedures are advised only to be performed in more controlled environments such as an operating room.<ref>{{Cite journal |last=Sarper Erikci |first=Volkan |date=2022-06-27 |title=Airway Foreign Bodies in Children: A Review Article |journal=Journal of Clinical Research and Reports |volume=11 |issue=3 |pages=01–04 |doi=10.31579/2690-1919/250 |s2cid=250541892 |issn=2690-1919|doi-access=free }}</ref> In unconscious choking victims, the American Medical Association has previously advocated sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions.<ref name="AMA">{{Cite book |url=https://archive.org/details/handbookoffirsta00amer |title=American Medical Association Handbook of First Aid and Emergency Care |date=2009-05-05 |publisher=[[Random House]] |isbn=978-1-4000-0712-7 |page=70 |quote=dislodge the object. |url-access=registration}}</ref> Many modern protocols suggest other treatment modalities are superior. Red Cross procedures also advise rescuers not to perform a finger sweep unless an object can be clearly seen in the victim's mouth to prevent driving the obstruction deeper into the victim's airway. Other protocols suggest that if the patient is conscious they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should place them in the [[recovery position]] to allow the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (inducing vomiting, for instance) by using a finger sweep technique. There are no studies that have examined the usefulness of the finger sweep technique when there is no visible object in the airway. Recommendations for the use of the finger sweep have been based on anecdotal evidence.<ref name=":2" />