🩺 Adult Choking Management

Adult Choking Management involves a sequence of manual manoeuvres designed to create an artificial cough and clear a Foreign Body Airway Obstruction (FBAO). The UK protocol, governed by the Resuscitation Council, uses a tiered approach: encouraging coughing for mild obstruction, followed by back blows and abdominal thrusts for severe obstruction. If the patient becomes unresponsive, the priority shifts to cardiopulmonary resuscitation. Timely intervention is life-saving and prevents progression to hypoxic brain injury or death.

Choking management is indicated when a patient shows signs of foreign body airway obstruction (FBAO). Signs of mild obstruction include being able to speak, cough, and breathe. Signs of severe obstruction include the inability to speak, a silent or ineffective cough, increasing respiratory distress, cyanosis, and the patient clutching their neck (the universal choking sign). Immediate intervention is required to prevent hypoxia, unconsciousness, and cardiac arrest.

Abdominal thrusts (Heimlich manoeuvre) are contraindicated in infants under 1 year of age (use chest thrusts instead) and should be avoided or modified in late-stage pregnancy or marked obesity, where chest thrusts are preferred. There are no contraindications to life-saving interventions in a completely obstructed airway, but the technique must be adjusted based on the patient's physical state. Blind finger sweeps are strictly contraindicated as they can push the foreign body deeper into the oropharynx.

Initially, no equipment is required as choking management relies on manual techniques. In a hospital setting, equipment that should be prepared includes high-flow oxygen, a Magill forceps (to remove visible objects under direct laryngoscopy), and a functioning suction unit (though this is rarely effective for solid objects). An emergency airway trolley, including equipment for a surgical cricothyroidotomy, should be available if manual manoeuvres and laryngoscopy fail to clear the airway.

Assess the severity: if the patient is coughing effectively, encourage them. If the cough is ineffective but the patient is conscious, give up to 5 sharp back blows between the shoulder blades with the patient leaning forward. If the obstruction persists, give up to 5 abdominal thrusts (Heimlich manoeuvre) by pulling inwards and upwards above the umbilicus. Continue alternating cycles of 5 back blows and 5 abdominal thrusts until the object is cleared or the patient becomes unconscious. If unconscious, lower the patient to the ground and start 30 chest compressions immediately, checking the mouth before delivering breaths.

Success is interpreted as the forceful expulsion of the foreign object followed by the patient's ability to breathe and speak clearly. If the patient's condition progresses from a 'strong' cough to a 'weak' cough, the obstruction is interpreted as becoming severe. If the patient loses consciousness, the interpretation shifts to a cardiac arrest scenario where the airway is likely still compromised. After successful removal, the patient should always be assessed for internal injuries caused by the manoeuvres.

A common error is performing abdominal thrusts on a patient who is still coughing effectively; this can convert a partial obstruction into a complete one. Another mistake is failing to lean the patient sufficiently forward during back blows, which may cause the object to travel further down the airway due to gravity. Using insufficient force during thrusts or failing to check the mouth for expelled objects before restarting cycles is also frequently seen. Rescuers often forget that once a patient becomes unconscious, they must transition immediately to BLS, starting with compressions regardless of a pulse.

Clearly ask the patient 'Are you choking?' at the start. If they can speak or cough, encourage them to continue coughing and do not intervene with manual thrusts. When performing back blows, use the heel of your hand and strike firmly between the shoulder blades. For abdominal thrusts, stand behind the patient, put your arms around their waist, and pull sharply inwards and upwards. Always verbalise that if the patient falls unconscious, you will catch them safely to the floor and start CPR.

Choking involves the 'Airway' section of the ABCDE assessment. For the MLA, students must distinguish between mild and severe obstruction and know the exact sequence of 5 back blows followed by 5 abdominal thrusts. Understanding the variations for special populations (infants, pregnant women) is a common exam theme. Candidates must also be aware that anyone who has received abdominal thrusts requires a medical review to check for visceral injury (e.g., splenic or hepatic rupture).