Management of choking in paediatric BLS

Foreign body airway obstruction (FBAO) is characterised by the sudden onset of respiratory distress associated with coughing, gagging, or stridor. Similar signs and symptoms may also be associated with other causes of airway obstruction, such as laryngitis or epiglottitis, which require different management. Suspect FBAO if:

• the onset was very sudden
• there are no other signs of illness
• there are clues to alert the rescuer, for example a history of eating or playing with small items immediately prior to the onset of symptoms

Overview of relief of FBAO:

Assess severity:

• if effective cough (see notes below) then:
  • encourage cough
  • continue to check for deterioration to ineffective cough or relief of obstruction
• if ineffective cough (see notes below) the:
  • if conscious then:
    • 5 back blows
    • 5 thrusts (chest for infant) (abdominal for child > 1)
  • if unconscious then:
    • open airway
    • 5 breaths
    • start CPR

Details:

• rescuers should avoid placing themselves in danger and consider the safest action to manage the choking child:
  • if the child is coughing effectively, then no external manoeuvre is necessary. Encourage the child to cough, and monitor continuously
  • if the child’s coughing is, or is becoming, ineffective, shout for help immediately and determine the child’s conscious level
• conscious child with FBAO
  • if the child is still conscious but has absent or ineffective coughing, give back blows
  • if back blows do not relieve the FBAO, give chest thrusts to infants or abdominal thrusts to children. These manoeuvres create an ‘artificial cough’ to increase intrathoracic pressure anddislodge the foreign body
• back blows in an infant:
  • support the infant in a head-downwards, prone position, to enable gravity to assist removal of the foreign body
  • a seated or kneeling rescuer should be able to support the infant safely across his lap
  • support the infant’s head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers from the same hand at the same point on the other side of the jaw
  • do not compress the soft tissues under the infant’s jaw, as this will exacerbate the airway obstruction
  • deliver up to 5 sharp back blows with the heel of one hand in the middle of the back between the shoulder blades.
  • the aim is to relieve the obstruction with each blow rather than to give all 5
• back blows in a child over 1 year:
  • back blows are more effective if the child is positioned head down
  • a small child may be placed across the rescuer’s lap as with an infant
  • if this is not possible, support the child in a forward-leaning position and deliver the back blows from behind
• if back blows fail to dislodge the object, and the child is still conscious, use chest thrusts for infants or abdominal thrusts for children. Do not use abdominal thrusts (Heimlich manoeuvre) for infants
• chest thrusts for infants:
  • turn the infant into a head-downwards supine position. This is achieved safely by placing your free arm along the infant’s back and encircling the occiput with your hand
  • support the infant down your arm, which is placed down (or across) your thigh
  • identify the landmark for chest compression (lower sternum approximately a finger’s breadth above the xiphisternum)
  • deliver 5 chest thrusts. These are similar to chest compressions, but sharper in nature and delivered at a slower rate
• abdominal thrusts for children over 1 year:
  • stand or kneel behind the child. Place your arms under the child’s arms and encircle his torso
  • clench your fist and place it between the umbilicus and xiphisternum
  • grasp this hand with your other hand and pull sharply inwards and upwards
  • repeat up to 5 times
  • ensure that pressure is not applied to the xiphoid process or the lower rib cage as this may cause abdominal trauma
• following chest or abdominal thrusts, reassess the child:
  • if the object has not been expelled and the victim is still conscious, continue the sequence of back blows and chest (for infant) or abdominal (for children) thrusts
  • call out, or send, for help if it is still not available
  • do not leave the child at this stage. If the object is expelled successfully, assess the child’s clinical condition. It is possible that part of the object may remain in the respiratory tract and cause complications. If there is any doubt, seek medical assistance. Abdominal thrusts may cause internal injuries and all victims so treated should be examined by a medical practitioner
• unconscious child with FBAO
  • if the child with FBAO is, or becomes, unconscious place him on a firm, flat surface.
  • call out, or send, for help if it is still not available
  • do not leave the child at this stage
  • airway opening:
    • open the mouth and look for any obvious object
    • if one is seen, make an attempt to remove it with a single finger sweep
    • do not attempt blind or repeated finger sweeps - these can impact the object more deeply into the pharynx and cause injury.
  • rescue breaths:
    • open the airway and attempt 5 rescue breaths
    • assess the effectiveness of each breath: if a breath does not make the chest rise, reposition the head before making the next attempt
  • chest compression and CPR:
    • attempt 5 rescue breaths and if there is no response, proceed immediately to chest compression regardless of whether the breaths are successful
    • follow the sequence for single rescuer CPR (see linked BLS guidance) for approximately 1 min before summoning emergency medical services (EMS) (if this has not already been done by someone else)
    • when the airway is opened for attempted delivery of rescue breaths, look to see if the foreign body can be seen in the mouth
    • if an object is seen, attempt to remove it with a single finger sweep
    • if it appears that the obstruction has been relieved, open and check the airway as above. Deliver rescue breaths if the child is not breathing
    • if the child regains consciousness and is breathing effectively, place him in a safe side-lying (recovery) position and monitor breathing and conscious level whilst awaiting the arrival of EMS

Notes:

• general signs of FBAO
  • witnessed episode
  • coughing or choking
  • sudden onset
  • recent history of playing with or eating small objects
• ineffective coughing
  • unable to vocalise
  • quiet or silent cough
  • unable to breathe
  • cyanosis
  • decreasing level of consciousness
• effective cough
  • crying or verbal response to questions
  • loud cough
  • able to take a breath before coughing
  • fully responsive

Reference:

1. BMJ editorial. New international concensus on cardiopulmonary resuscitation. BMJ 2005;331:1281-2.
2. Resuscitation 2005;67:181-341.