How to manage a choking adult

Rationale and key points

Choking, or foreign body airway obstruction, is a common, yet treatable, cause of accidental death. This How to module aims to provide an overview of the skills required when faced with this emergency in adults, including how to recognise this emergency, the immediate management and treatment required, and the necessary aftercare.

• Choking usually occurs when a person is eating or drinking.
• An obstruction may be classified as mild or severe.
• For a severe obstruction in a conscious person, it may be necessary to administer back blows and/or abdominal thrusts to remove the obstruction from the airway.

Keywords

clinical procedures, clinical skills, choking, foreign body airway obstruction, emergency care, cardiopulmonary resuscitation, CPR, resuscitation

Learning objectives

After reading this module you should be able to:

• Recognise when choking occurs and list the signs and symptoms of choking.
• Quickly assess whether an obstruction is mild or severe.
• Describe the various techniques for removing an obstruction from the airway in a conscious person.

Procedure
In an emergency situation where a person appears to be choking, it is essential that you remain calm. If possible, identify telephone access to summon emergency medical services, should this be required. Recognise the emergency. Choking usually occurs when a person is eating or drinking, therefore operate a high index of suspicion if the person begins to cough suddenly or if they appear distressed or afraid. Other signs of airway compromise the person may display include grabbing at their neck or trying to attract the attention of others if they are unable to speak.	Check the environment is safe before you approach the person.
Figure 1 Assess the severity of the airway obstruction (Figure 1) and ask the person: ‘are you choking?’. If they are able to speak, breathe and cough, they are likely to have a mild airway obstruction (Perkins et al 2015). If they cannot speak, have a weakening cough, and are struggling or unable to breathe, they have a severe airway obstruction (British Heart Foundation 2010, Perkins et al 2015). If the person cannot speak they may only nod in response.	For a mild airway obstruction, encourage the person to cough (Perkins et al 2015). If this is ineffective in dislodging the obstruction, follow the steps below.
Figure 2 For a severe airway obstruction in a conscious person, administer back blows immediately (Figure 2).	Figure 3 If back blows are ineffective in clearing the airway, you must deliver up to five abdominal thrusts (Figure 3).
If the obstruction has not been removed after five abdominal thrusts and the person is still conscious, continue an alternating pattern of five back blows, followed by five abdominal thrusts (Perkins et al 2015).	Figure 4 If the person becomes unconscious, you must summon emergency medical services immediately. If other personnel are present, instruct them to do this while you continue with the rescue as follows: Lower the person to the floor and lay them flat on their back. Commence cardiopulmonary resuscitation (CPR) with chest compressions (Figure 4).
Following successful treatment, refer the person for a medical examination to assess for potential injury from vigorous back blows and abdominal thrusts. If the person is pregnant or too large for the rescuer to encircle them with their arms, chest thrusts are an alternative to abdominal thrusts. To perform chest thrusts on a standing person: Stand behind the person. Place your arms around them and position a clenched fist of one hand on the centre of the chest. Grasp this with the other hand and pull inwards. Continue until the obstruction is dislodged or the person becomes unconscious. If the person becomes unconscious, follow the stages in Figure 4.

Learning points

1. Choking usually occurs when a person is eating or drinking, therefore if a person begins to cough suddenly, appears distressed or afraid or grabs at their neck, choking should be suspected.
2. The severity of airway obstruction can be categorised as either mild or severe, and treatment varies depending on the level of severity. For a mild airway obstruction, the person should be encouraged to cough. For severe obstruction in a conscious person, back blows should be administered.
3. If back blows are ineffective in clearing the airway, five abdominal thrusts should be delivered. If the obstruction has not been removed after five abdominal thrusts and the person is still conscious, an alternating pattern of back blows and abdominal thrusts is advocated.
4. If the person becomes unconscious, summon the emergency services immediately and commence CPR with chest compressions.
5. The chest should be compressed by 5-6cm at a rate of 100-120 per minute, allowing for full chest recoil after each compression. A total of 30 compressions should be delivered followed by an attempt at 2 ventilations, as per Resuscitation Council (UK) guidelines (Perkins et al 2015).