Heimlich maneuver

Definition

The Heimlich maneuver is an emergency technique for removing a foreign object lodged in the airway that is preventing a child or an adult from breathing.

Purpose

The Heimlich maneuver is used when a person is choking on a foreign object to the extent that he/she cannot breathe. Oxygen deprivation from a foreign body airway obstruction can result in permanent brain damage or death in four minutes or less. Using the Heimlich maneuver can save a choking victim's life. The Heimlich maneuver is not performed on infants under one year of age (see below for technique for infants). Indications that a choking victim's airway is blocked include the following:

• inability to cough , cry, or speak
• blue or purple face color from lack of oxygen
• grabbing at throat
• weak cough and labored breathing that produces a high-pitched noise
• all of the above, followed by loss of consciousness

Each year, more than 17,000 infants and children are treated in hospital emergency departments for choking-related incidents, and more than 80 percent of these occur in children aged four years and younger. Airway obstruction death and injury are especially prevalent in children under age four due to their anatomy (small airway), natural curiosity and tendency to put objects in their mouths, and incomplete chewing. In infants, choking usually results from inhalation of small objects (e.g., coins, small toys , deflated balloons, buttons) that they place in their mouth.

Description

In 1974, Henry Heimlich first described an emergency technique for expelling foreign material blocking the trachea. This technique, now called the Heimlich maneuver, is simple enough that it can be performed immediately by anyone trained in the maneuver. The Heimlich maneuver is a standard part of all first-aid and cardiopulmonary resuscitation (CPR) courses.

The theory behind the Heimlich maneuver is that by compressing the abdomen below the level of the diaphragm with quick abdominal thrusts, an "artificial cough" is created. Air is forced out of the lungs to dislodge the obstruction in the trachea and bring the foreign object back up into the mouth.

The Heimlich maneuver can be performed on all people; however, modifications are necessary infants, children, obese individuals, and pregnant women.

Performing the Heimlich maneuver on children

To perform the Heimlich maneuver on a conscious child, the rescuer stands or kneels behind the child, who may be seated or standing. The rescuer makes a fist with one hand, and places it, thumb toward the child, below the rib cage and above the waist. The rescuer encircles the child's waist, placing his other hand on top of the fist then gives a series of five quick and distinct inward and upward thrusts. If the foreign object is not dislodged, the cycle of five thrusts is repeated until the object is expelled or the child becomes unresponsive. As the child is deprived of oxygen, the muscles of the trachea relax slightly, and it is possible that the foreign object may be expelled on a second or third attempt.

If the victim is unconscious or becomes unconscious, the rescuer should lay him or her on the floor, bend the chin forward, make sure the tongue is not blocking the airway, and feel in the mouth for the foreign object, being careful not to push any farther into the airway. The rescuer kneels astride the child's thighs and places his fists between the bottom of the victim's breast-bone and the navel. The rescuer then executes a series of five quick compressions by pushing inward and upward.

After the abdominal thrusts, the rescuer repeats the process of lifting the chin, moving the tongue, feeling for and possibly removing the foreign material. If the airway is not clear, the rescuer repeats the abdominal thrusts as often as necessary. If the foreign object has been removed, but the victim is not breathing, the rescuer starts CPR.

The technique in children over one year of age is the same as in adults, except that the amount of force used is less than that used with adults in order to avoid damaging the child's ribs, breastbone, and internal organs.

OBESE CHILDREN AND ADOLESCENTS The main difference in performing the Heimlich maneuver on an obese victim is in the placement of the fists. Instead of using abdominal thrusts, chest thrusts are used. The fists are placed against the middle of the breastbone, and the motion of the chest thrust is in and downward, rather than upward. If the victim is unconscious, the chest thrusts are similar to those used in CPR.

Foreign body obstruction in infants under age one year

The Heimlich maneuver as described above is not performed on infants under one year of age. Instead, a series of back blows and chest thrusts are used. The rescuer sits down and lays the infant along his or her fore-arm with the infant's face pointed toward the floor and tilted downward lower than the body. The rescuer's hand supports the infant's head, and his or her forearm rests on his or her own thigh for additional support. Using the heel of the other hand, the rescuer administers five rapid blows to the infant's back between the shoulder blades.

After administering the back blows, the rescuer sandwiches the infant between his or her arms and turns the infant over so that the infant is lying face up supported by the opposite arm. Using the free hand, the rescuer places the index and middle finger on the center of the breastbone just below the nipple line and makes gives five quick chest thrusts. This series of back blows and chest thrusts is alternated until the foreign object is expelled. If the infant becomes unconscious, CPR should be initiated.

Precautions

Any lay person can be trained to perform the Heimlich maneuver and to know how may save someone's life. Before doing the maneuver, it is important to determine if the airway is completely blocked. If the victim choking can talk or cry, the Heimlich maneuver should not be administered. If the airway is not completely blocked, the choking victim should be allowed to try to cough up the foreign object on his or her own.

Aftercare

Vomiting may occur after being treated with the Heimlich maneuver. All infants and children who experience a choking episode severe enough to require the Heimlich maneuver should be taken to the hospital emergency room to be examined for airway injuries.

Risks

Incorrectly applied, the Heimlich maneuver can break bones or damage internal organs. In infants, the rescuer should never attempt to sweep the baby's mouth without looking to remove foreign material. This is likely to push the material farther down the trachea. Following the Heimlich maneuver, dysphagia (swallowing difficulty) and obstructive pulmonary edema (fluid accumulation in the lungs) may occur.

Normal results

In many cases the foreign material is dislodged from the throat, and the choking victim suffers no permanent effects of the episode. If the foreign material is not removed, the choking victim may suffer permanent brain damage from lack of oxygen or may die.

Parental concerns

Because most choking incidents occur in the home, all parents and infant/child caregivers should be trained in the Heimlich maneuver. Training is available through the American Red Cross and American Heart Association at local schools, YMCAs, and community centers.

The likelihood of choking incidents can be reduced by closely supervising infants and children while eating and playing. Most choking incidents are associated with food items, especially hot dogs, candies, grapes, nuts, popcorn, and carrots. Common non-food items that are choking hazards include deflated balloons, buttons, coins, small balls, small toys, and toy parts. All toys should be examined to make sure they are age-appropriate and do not have loose parts.

Resources

BOOKS

Basic Life Support for Healthcare Providers. Dallas, TX: American Heart Association, 2001.

PERIODICALS

Ringold, Sarah, et al. "Postobstructive Pulmonary Edema in Children." Pediatric Emergency Care 20 (June 2004): 391–95.

Vilke, Gary M., et al. "Airway Obstruction in Children Aged Less Than 5 Years: The Prehospital Experience." Prehospital Emergency Care 8 (2004): 196–99.

ORGANIZATIONS

American Heart Association. 7320 Greenville Ave. Dallas, TX 75231. Web site: http://www.americanheart.org.

The Heimlich Institute. 311 Straight St., Cincinnati, OH 45219–9957. Web site: http://www.heimlichinstitute.org.

WEB SITES

"Heimlich Maneuver." American Heart Association , 2004. Available online at http://www.americanheart.org/presenter.jhtml?identifier=4605 (accessed November 20, 2004).

"Infant First Aid for Choking and CPR: An Illustrated Guide." BabyCenter , 2004. Available online at http://www.babycenter.com/general/9298.html (accessed November 20, 2004).

Jennifer E. Sisk, MA