2.5 Choking, Foreign-Body Airway Obstruction, and Opioids

2.5 Choking, Foreign-Body Airway Obstruction, and Opioids

This section covers two BLS emergencies that are not cardiac arrest but can rapidly become one: foreign-body airway obstruction (FBAO, choking) and opioid-associated emergencies. Both are explicit topics in the current AHA adult BLS guidance, and exam items test the ability to grade severity and choose the right intervention.

Choking: mild vs. severe

The first decision is severity, judged by air exchange.

For mild obstruction, the patient's own cough is the most effective force — interfering can dislodge the object into a worse position. Stay with the patient and be ready to escalate if it worsens.

For severe obstruction in a responsive adult or child, activate EMS and alternate 5 back blows with 5 abdominal thrusts until the object clears or the person becomes unresponsive. In late pregnancy, or when the rescuer cannot encircle an adult’s abdomen, alternate 5 back blows with 5 chest thrusts. For an infant under 1 year, use 5 back blows followed by 5 chest thrusts, never abdominal thrusts. These sequences follow the 2025 AHA adult BLS guidance and pediatric guidance.

When the choking patient becomes unresponsive

If the choking victim loses consciousness, the sequence changes to CPR. Lower the patient safely to the ground, activate the emergency response system (or send someone), and begin CPR starting with chest compressions. Each time you open the airway to give breaths, look inside the mouth; if you see the object, remove it. Do not perform blind finger sweeps — they can push the object deeper. The chest compressions themselves help generate pressure that may expel the obstruction. Continue cycles of compressions, airway checks, and breaths until the object clears or advanced help takes over.

Opioid-associated emergencies

The opioid epidemic prompted the AHA to integrate naloxone into BLS algorithms. Suspect an opioid emergency when an unresponsive patient has slow or absent breathing and pinpoint pupils, often with circumstantial clues (paraphernalia, known use). The critical BLS distinction is pulse status:

• Pulse present, not breathing normally (opioid-associated respiratory arrest): The priority is ventilation — open the airway and give rescue breaths (1 every 6 seconds). Administer naloxone (intramuscular or intranasal) and continue supporting breathing until breathing returns or EMS arrives. Naloxone is an opioid antagonist; it reverses respiratory depression but takes minutes to work, so ventilation is never withheld while waiting.
• No pulse (cardiac arrest): Begin standard high-quality CPR immediately. Naloxone may be given as an adjunct, but it must never delay or replace compressions and defibrillation, because in true cardiac arrest the problem is no circulation, not just opioid effect.

Why pulse status drives the decision

The trap on exam items is giving naloxone instead of CPR in a pulseless patient. Naloxone treats the opioid, but a pulseless patient needs circulation restored first. Conversely, in a patient who still has a pulse, aggressive ventilation plus naloxone can prevent the slide into full arrest. Always re-check breathing and pulse after naloxone, and be prepared for the patient to wake combative or to re-sedate as naloxone wears off (it can be shorter-acting than the opioid).

Common traps

• Intervening on a mild choker who is coughing forcefully.
• Performing blind finger sweeps in an unresponsive patient.
• Using abdominal thrusts on an infant (should be back slaps + chest thrusts).
• Giving naloxone in place of CPR when the patient is pulseless.

Naloxone dosing and re-dosing

For NARCAN 4 mg nasal spray, give one spray into one nostril for a suspected opioid emergency and call emergency services. If the person does not respond or respiratory depression returns, the product label directs another dose with a new device every 2–3 minutes, alternating nostrils, until help arrives. Continue indicated rescue breathing or CPR while waiting; other naloxone products may have different strengths or instructions. FDA-approved product labeling. After naloxone, watch for two outcomes: the patient wakes and may be agitated or in acute withdrawal, or the patient re-sedates as the dose fades and needs another. Naloxone has no effect on a non-opioid cause of unresponsiveness, so if there is no response, do not anchor on opioids — reassess airway, breathing, circulation, and other reversible causes.

The opioid-associated algorithm in one picture

The table captures the entire decision: pulse present drives ventilation plus naloxone; pulse absent drives CPR. This section ties the whole chapter together because it forces the rescuer to integrate recognition, the breathing-and-pulse check, high-quality compressions, ventilation, and the AED into a single judgment under time pressure — exactly the discrimination the BLS and ACLS exams are built to test.