Airway and Breathing Emergencies

Choking

A person chokes when the airway is partly or completely blocked and airflow to the lungs is reduced or cut off. The choking casualty either has trouble breathing or cannot breathe at all.

In infants and young children, choking can be caused by foreign objects, such as food, toys, buttons, coins, etc. Adults usually choke on food while eating too fast or talking while eating.

When a casualty is unresponsive and lying on their back, their tongue may relax and block their airway. As well, blood, vomit, or other fluids can pool in the back of the mouth. Severe allergic reaction, injury, or other medical conditions can cause the airway to swell.

The severity of choking depends on how blocked the airway is. A person breathing normally without any obstruction will have an open and clear airway.

Mild choking occurs when the airway is only partially blocked and the casualty can still cough forcefully, breathe, and speak. The air exchange is affected, but still considered good.

Severe choking occurs when the airway is completely blocked and there is no air exchange.

When the air supply to the lungs is cut off, the person’s face will at first have a more noticeable red undertone (flushed) before becoming grey. Their lips and ear lobes will begin to turn blue due to a lack of oxygen. If they do not receive help, they will become unconscious, and their heart will stop beating.

Signs and Symptoms of Choking

The signs and symptoms of choking are as follows.

Signs of Choking
Mild Obstruction	Severe Obstruction
Able to speak	Unable to speak
Signs of distress (eyes show fear)	Signs of distress (eyes show fear)
Forceful coughing	Weak or no coughing
Wheezing and gagging between coughs	High-pitched noise or no noise when trying to breathe
Red or “flushed” face	Grey face and blue lips and ears

Managing a Choking Emergency for Adults and Children

Choking in adults and children is managed the same way.

When providing first aid to a child who is choking, keep the following in mind:

Lower yourself down to their level. Do not put them on a chair or stool.
Do not use the same force for thrusts as you might for an adult.
You may only need one hand if they are unresponsive.

First aid for a responsive casualty

If the obstruction is mild and the casualty can cough forcefully, speak, or breathe, perform the following steps:

Perform a scene survey.
Tell them to try to cough up the object. If a mild obstruction lasts for a few minutes, get medical help.

If the obstruction is severe and the casualty cannot cough forcefully, speak, or breathe, perform the following steps:
Perform a scene survey.
Give 5 back blows:
• Support the casualty by bringing your hand across the casualty’s shoulders on the front of their body.
• Give up to five blows between the shoulder blades using the heel of your hand.
Give 5 abdominal thrusts:
• If the obstruction is not cleared, step behind the casualty, preparing to support them if they become unconscious.

• Make a fist and place it on the casualty’s abdomen at the belly button, in line with the hip bones.

• Grasp the fist with the other hand and give 5 forceful inward and upward abdominal thrusts.

Continue with back blows and abdominal thrusts until the object is cleared or the casualty becomes unresponsive.

If the airway is cleared, an adult casualty should seek medical attention to check for internal injury from the abdominal thrusts.

A child casualty needs to be seen by a doctor.

How abdominal thrusts work

When you choke on something, your body tries to unblock your airway by coughing. Abdominal thrusts try to do the same thing with an artificial cough. This illustration shows how an abdominal thrust creates a cough.

An abdominal thrust pushes the diaphragm up towards the lungs very quickly. This forces the air from the lungs up the airway and hopefully blows the obstruction out. For the best effect, the fist must be in the correct place. Keep your forearms off the abdomen and make each thrust a strong and sudden movement.

First aid for a casualty who is pregnant or larger than the rescuer

If a choking casualty is larger or is pregnant, give back blows as normal, followed by chest thrusts.

Support the casualty by bringing your hand across their shoulders on the front of their body. Give up to five back blows between the shoulder blades, using the heel of your hand.
If the obstruction is not cleared, stand behind the casualty.
Keep your arms horizontal and snug up under their armpits.
Place your fist against the lower half of the breastbone, thumb side in.
Hold your fist with your other hand. Pull inward forcefully.
Continue giving back blows and chest thrusts until either the object is removed, or the casualty becomes unconscious.

First aid for a choking casualty in a wheelchair

Some wheelchairs will allow the first aider to provide abdominal or chest thrusts as they would for a casualty who is standing.

If you can reach around from behind the wheelchair, give back blows as normal, and abdominal or chest thrusts.

If you cannot reach around the wheelchair, perform the following steps:

Position the wheelchair against a wall (if possible) and put the wheelchair brake on.
If possible, carefully lean the casualty forward and support their shoulders. Perform five back blows between the shoulder blades, using the heel of your hand.
Put the heel of one hand, with the other on top, on the centre of the breastbone and give firm chest thrusts.
Continue giving back blows and chest thrusts until either the object is removed or the casualty becomes unconscious.

If a doctor, physiotherapist, or other health professional has shown you a different way of giving abdominal thrusts to a person in your care, use the recommended method.

If the casualty becomes unresponsive, you will need to take them out of the wheelchair.

First aid for a casualty who goes unresponsive

If the casualty becomes unresponsive while providing first aid for choking, use a modified CPR approach.

Ease the casualty to the ground if you can do so without hurting yourself. At minimum, protect their head as they collapse.
Call for medical help and get an AED if available.
Give 30 chest compressions in the centre of their chest.
Open their airway using the head-tilt/chin-lift and check their mouth.
Remove any foreign object you can see.
Try to give 2 ventilations even if you did not find anything in their mouth.
If the ventilations do not go in, readjust their head. This may be an indication that you may not have opened the airway properly the first time.
Attempt to give 2 ventilations.
If the ventilations still do not go in, resume compressions, mouth checks, and attempts to ventilate.

Once a ventilation is successful, deliver a second ventilation. Be ready to continue CPR if the casualty does not start breathing on their own.

If the casualty is a child, begin with one hand when giving compressions. If you are not able to compress the chest enough, use two hands.

First aid if you are alone and choking

If you begin to choke on an object, you may have to clear your own airway. If there are people around, get their attention. Do not isolate yourself from others.

Try to cough up the object. If you cannot cough, speak, or breathe:

Give yourself abdominal thrusts:

Place the fist of one hand just above your bellybutton.
Use your other hand to thrust inward and upward.
Repeat until the object is cleared or you can cough or breathe.
Use a solid object like the back of a chair, a table, or the edge of a counter.
Position yourself so the object is just above your hips.
Press forcefully to produce an abdominal thrust.

Managing a Choking Emergency for Infants

Infants are at risk for choking since they are frequently putting things into their mouths. A choking infant will show some or all of the following signs:

High-pitched wheezing or no sound at all
Gagging
Appearance of crying with no sound
Wide eyes
Changing colour

First aid for a choking infant who is responsive

To give first aid for a choking infant who is responsive, perform the following steps:

Perform a scene survey and primary survey.
Support the infant’s head using a “C” grip around their chin.
Place the infant face down on your forearm with their legs on either side of your arm.
With the infant’s head lower than their body, use the heel of your hand to give five forceful back blows between their shoulder blades.
Use your other arm and hold the infant between your forearms, supporting the back of the infant’s head.
Turn the infant face up.
Give five chest thrusts using 2 fingers just below their nipple line.

Keep giving back blows and chest thrusts until their airway is cleared or the infant becomes unresponsive. An infant who chokes needs to be seen by a doctor.

First aid for a choking infant who becomes unresponsive

If the infant becomes unresponsive, place them on a firm, flat surface and perform the following steps:

Send someone to call 9-1-1 or call yourself and place the phone on speaker mode.
Using two fingers below the infant’s nipple line, deliver 30 compressions.
Open their airway using the head-tilt/chin-lift and check their mouth.
Remove any foreign object you can see.
Try to give 2 ventilations even if you did not find anything in their mouth.
If the ventilations do not go in, readjust their head. This may be an indication that you may not have opened the airway properly the first time.
Attempt to give 2 ventilations.
If the ventilations still do not go in, resume compressions, mouth checks, and attempts to ventilate.

An infant’s lungs are much smaller than those of an adult. When giving ventilations, do not blow forcefully, and only give enough for the chest to rise (often described as a “cheek-full” of air).

Because an infant’s head is larger than their body proportionally, you may need to place a folded towel or blanket under their shoulders to allow for a proper head-tilt.