7.4 Choking Dispatch Life Support: Conscious Heimlich, Unconscious Choking & Infant Maneuvers
Key Takeaways
- The MPDS choking protocol strictly distinguishes between partial obstruction (forceful coughing, speaking—do not interfere) and complete foreign body airway obstruction (aphonia, silent cough, cyanosis—immediate DLS intervention).
- Conscious adults and children with complete obstruction require abdominal thrusts (the Heimlich maneuver) directed inward and upward midway between the navel and the xiphoid process.
- Chest thrusts are mandatory for conscious choking victims who are visibly in the late stages of pregnancy or morbidly obese where abdominal encircling is ineffective or unsafe.
- Conscious choking infants (<1 year) require cycles of 5 back slaps followed by 5 chest thrusts; if any choking victim becomes unconscious, the EMD immediately transitions to CPR chest compressions with strictly NO blind finger sweeps.
7.4 Choking Dispatch Life Support: Conscious Heimlich, Unconscious Choking & Infant Maneuvers
Quick Answer: The Medical Priority Dispatch System (MPDS) choking pathway (Protocol 11 / DLS) hinges on a fundamental clinical threshold: Partial vs. Complete Airway Obstruction. If the patient is coughing forcefully, wheezing, or speaking, the EMD must never interfere, instructing the caller to encourage coughing. If the patient has a complete obstruction (unable to speak, silent cough, cyanosis), immediate physical intervention is required. For conscious adults/children, the EMD coaches abdominal thrusts (Heimlich maneuver); for pregnant or morbidly obese victims, chest thrusts are used. For conscious infants (<1 year), the protocol mandates alternating 5 back slaps and 5 chest thrusts (abdominal thrusts are strictly prohibited). If any choking victim loses consciousness, the rescuer must immediately transition to CPR chest compressions to expel the object with intrathoracic pressure—and blind finger sweeps are strictly forbidden.
Triage Assessment: Partial vs. Complete Foreign Body Airway Obstruction (FBAO)
When a 9-1-1 call involves a choking individual, the EMD's first responsibility during Case Entry and Protocol 11 Key Questions is determining whether the airway is partially or completely occluded.
+=============================================================================+
| FBAO CLINICAL ASSESSMENT & TRIAGE PATHWAY |
| |
| PARTIAL AIRWAY OBSTRUCTION: |
| - Patient can speak, vocalize, cry, or cough forcefully |
| - Audible wheezing or whistling sounds between coughs |
| --> DISPATCH ACTION: DO NOT INTERFERE! Encourage continued coughing. |
| |
| COMPLETE AIRWAY OBSTRUCTION: |
| - Complete aphonia (inability to speak, vocalize, or cry) |
| - Silent, ineffective cough attempts |
| - Universal choking sign (hands clutched to throat), cyanosis |
| --> DISPATCH ACTION: IMMEDIATE DISPATCH LIFE SUPPORT (DLS) INTERVENTIONS |
+=============================================================================+
The Cardinal EMD Rule: Never Interfere with a Forceful Cough
A spontaneous physiological cough generates subglottic airway pressures that exceed 100 to 150 mmHg—far greater than any artificial pressure produced by manual thrusts or back blows.
If a patient is coughing forcefully:
- The airway is partially patent, and air is actively exchanging.
- Delivering back slaps or abdominal thrusts while the patient is coughing can dislodge the foreign body from the supraglottic area and wedge it tightly into the narrow subglottic space or vocal cords, transforming a manageable partial obstruction into an instantly fatal total obstruction.
- The scripted instruction is unequivocal: "Stay with him. Encourage him to keep coughing as hard as he can. Do not hit him on the back!"
Conscious Adult and Child Maneuvers: Abdominal Thrusts (Heimlich Maneuver)
When a conscious adult or child (>1 year of age) exhibits complete foreign body airway obstruction, the EMD immediately launches the scripted Dispatch Life Support pathway for abdominal thrusts.
+-----------------------------------------------------------------------------+
| ABDOMINAL THRUSTS (HEIMLICH MANEUVER) |
| |
| 1. Rescuer Stance: Stand directly behind the victim; wrap arms around |
| their waist. |
| 2. Landmark: Make a fist; place thumb-side against the abdomen |
| just above the navel (well below the xiphoid process)|
| 3. Grip: Grasp the fist firmly with the other hand. |
| 4. Vector of Force: Deliver quick, distinct, upward and inward thrusts |
| (a sharp 'J-hook' motion into the abdomen). |
| 5. Repetition: Repeat continuous thrusts until the object is |
| expelled or the patient becomes unconscious. |
+-----------------------------------------------------------------------------+
Biomechanical Mechanism
Delivering forceful inward and upward thrusts into the soft epigastric region abruptly elevates the diaphragm into the thoracic cavity. This sudden compression of the lungs increases alveolar pressure, forcing residual air up through the trachea to pop the lodged object out of the larynx like a cork from a bottle.
Anatomical Hazards and Landmark Verification
The EMD must emphasize proper hand placement:
- The fist must be placed above the umbilicus and well below the lower tip of the breastbone (xiphoid process).
- Directing force against the xiphoid process can fracture the bone, driving it into the left lobe of the liver or the diaphragm.
- Compressing too low or over the lateral costal margins risks splenic rupture, gastric perforation, or mesenteric lacerations.
Specialized Conscious Populations: Chest Thrusts for Pregnancy & Morbid Obesity
In specific clinical situations, standard abdominal thrusts cannot be performed safely or effectively:
+=============================================================================+
| CHEST THRUSTS: SPECIAL POPULATIONS |
| |
| Indications: |
| 1. Late-Stage Pregnancy: Abdominal thrusts risk uterine rupture, |
| placental abruption, and fetal trauma. |
| 2. Morbid Obesity: Rescuer's arms cannot encircle the victim's |
| abdominal circumference; abdominal fat pad |
| absorbs and dissipates inward force. |
+=============================================================================+
Scripted Chest Thrust Technique
When the caller reports the choking victim is visibly pregnant or too large to reach around:
- Positioning: Stand directly behind the victim (or have the victim lean against a wall) and bring arms under the victim's armpits.
- Landmark: Place the thumb-side of the fist directly against the center of the breastbone (sternum), at the level of the armpits (identical to the adult CPR compression landmark).
- Force Vector: Grasp the fist with the other hand and pull straight back with sharp, forceful backward thrusts.
- Mechanism: Chest thrusts directly compress the thoracic cavity, generating peak airway pressures without compressing the gravid uterus or dissipating force into abdominal adipose tissue.
The Lone Choking Rescuer (Self-Heimlich)
If a caller is alone and choking, the EMD coaches self-relief:
"Lean forward over the back of a sturdy chair, railing, or edge of a counter. Press your upper belly hard against the edge with quick upward thrusts!"
Conscious Infant Choking (<1 Year): Back Slaps and Chest Thrusts
Under no circumstances should abdominal thrusts ever be performed on an infant under one year old.
Why Abdominal Thrusts Are Contraindicated in Infants
An infant's abdominal anatomy is profoundly vulnerable:
- The liver is disproportionately large and extends down into the epigastrium and right abdomen without bony rib cage protection.
- The spleen and stomach are friable and susceptible to blunt trauma.
- Performing abdominal thrusts on an infant frequently results in fatal liver laceration, massive internal exsanguination, or diaphragmatic rupture.
STEP 1: 5 FIRM BACK SLAPS STEP 2: 5 CHEST THRUSTS
========================= =======================
[ Infant Prone ] [ Infant Supine ]
- Head lower than trunk - Head lower than trunk
- Support jaw & forearm - Support occiput & spine
- 5 slaps between scapulae - 5 thrusts below nipple line
with heel of hand with two fingers
The Scripted Infant Protocol: 5 Back Slaps & 5 Chest Thrusts
- Position for Back Slaps: The rescuer sits down and rests their forearm on their thigh. The infant is placed face down (prone) along the forearm, with the head angled downward lower than the chest. The rescuer supports the infant's jaw between the thumb and fingers, taking strict care not to compress the soft tissues of the throat or cover the mouth.
- Deliver 5 Back Slaps: Deliver up to 5 firm, distinct slaps in the middle of the back between the shoulder blades using the heel of the free hand.
- Transition to Chest Thrusts: The rescuer places their free forearm along the infant's back, cradling the occiput with their hand. Supporting the head and neck securely, the rescuer flips the infant onto their back (supine) along the other forearm, keeping the head lower than the torso.
- Deliver 5 Chest Thrusts: Place two fingers in the center of the chest, just below the nipple line. Deliver up to 5 quick downward chest thrusts (depth ~1.5 inches / 4 cm).
- Cycle: Repeat cycles of 5 back slaps and 5 chest thrusts until the foreign body is dislodged or the infant loses consciousness.
The Unconscious Choking Transition & The Absolute Ban on Blind Finger Sweeps
If manual thrusts fail to dislodge the foreign body, cerebral hypoxia leads to complete loss of consciousness within 60 to 90 seconds.
1. The Moment of Collapse: Transition to CPR
The moment the caller states that the choking adult, child, or infant has gone limp or stopped responding, the EMD terminates choking thrusts and immediately commands:
"Get him flat on his back on the floor right now! We are going to start chest compressions!"
2. Biomechanical Superiority of Chest Compressions
Transitioning to chest compressions is backed by rigorous clinical evidence:
- Loss of consciousness causes complete relaxation of the pharyngeal and laryngeal muscles, frequently allowing a tightly wedged object to loosen.
- Rhythmic chest compressions generate intrathoracic and subglottic pressures that are equal to or greater than manual abdominal thrusts.
- Compressions simultaneously maintain coronary and cerebral perfusion, slowing the progression of anoxic brain injury.
3. The Unconscious Choking Protocol Sequence
For any choking victim who becomes unresponsive, the EMD coaches the following repeating cycle:
- 30 Chest Compressions: Deliver 30 continuous compressions in the center of the chest.
- Airway Inspection: Open the mouth wide and look inside.
- "Look inside his mouth. If you see the object, swipe it out with your hooked finger!"
- If nothing is seen, do not touch the inside of the mouth.
- Attempt Ventilations: Give 2 breaths. If air goes in and chest rises, ventilations are working. If the chest does not rise, do not spend more than a few seconds attempting breaths.
- Resume Compressions: Immediately return to 30 chest compressions.
+=============================================================================+
| THE ABSOLUTE BAN ON BLIND FINGER SWEEPS |
| |
| NEVER perform a finger sweep unless the foreign object is VISUALLY SEEN! |
| |
| 1. Blind Sweeps Push Objects Deeper: A finger inserted without direct |
| visualization acts as a piston, ramming loose objects past the vocal |
| cords into the subglottic trachea, turning an accessible object into |
| a surgical airway emergency. |
| 2. Soft Tissue Lacerations: Rescuers blindly gouging the posterior |
| pharynx cause mucosal tearing, profuse bleeding, and vocal cord edema. |
| 3. Rescuer Injury: Unconscious patients experiencing anoxic reflexes can |
| clamp down with their jaw, severing the rescuer's finger. |
+=============================================================================+
Comprehensive Choking DLS Protocol Matrix
| Patient Category | Airway Status | Primary Dispatch Intervention | Critical Landmark & Technique | Fatal Pitfall to Avoid |
|---|---|---|---|---|
| Adult / Child | Partial (Coughing) | Conservative Observation | Encourage spontaneous coughing | Never hit on back; risks lodging object |
| Adult / Child | Complete (Conscious) | Abdominal Thrusts (Heimlich) | Inward/upward thrusts midway between navel and xiphoid | Compressing xiphoid process (liver rupture) |
| Pregnant / Obese | Complete (Conscious) | Chest Thrusts | Thumb-side fist against center of sternum | Compressing gravid uterus or lower abdomen |
| Infant (<1 Year) | Complete (Conscious) | Alternating 5 Back Slaps & 5 Chest Thrusts | Prone back slaps between scapulae; supine 2-finger thrusts below nipples | Abdominal thrusts STRICTLY BANNED (organ rupture) |
| Any Age | Unconscious Choking | Immediate CPR Compressions | 30 compressions -> Look in mouth -> 2 breaths -> Compressions | Blind finger sweeps STRICTLY BANNED |
Realistic Dispatch Transcript: Conscious Choking Collapse to Unconscious CPR
EMD: "9-1-1 Emergency, what is the address of the emergency?"
CALLER: "The Grand Bistro, 102 Market Street! A man is choking on food!"
EMD: "What is the phone number?"
CALLER: "555-0177."
EMD: "Tell me exactly what happened."
CALLER: "He was eating steak. He stood up, grabbed his throat, and he can't breathe!"
EMD: "Can he speak, or make any sound at all?"
CALLER: "No! Nothing! His face is turning purple! He's panicking!"
[SYSTEM TRIGGERS 11-E-1 ECHO CHOKING DISPATCH]
EMD: "I am sending the paramedics to help you right now. Stay on the line.
I am going to tell you how to clear his airway. Stand directly behind him."
CALLER: "I'm behind him."
EMD: "Wrap your arms around his waist. Make a fist with one hand and put the
thumb-side against his belly, just above his belly button. Grasp your
fist with your other hand."
CALLER: "Got it!"
EMD: "Pull inward and upward with quick, hard thrusts! As if you are trying
to lift him off the ground! Keep doing it!"
CALLER: "I'm doing it! 1... 2... 3... (screams) Oh no, he just collapsed!
He went completely limp on the floor!"
EMD: "Listen to me carefully! Get him flat on his back on the floor right now!
We are switching to chest compressions!"
CALLER: "Should I stick my finger down his throat?!"
EMD: "DO NOT put your fingers in his mouth unless you see the food!
Put the heel of your hand on the center of his chest between his nipples.
Lock your elbows. Push down hard and fast, 30 times! Count with me!
1, 2, 3, 4, 5, 6, 7, 8, 9, 10..."
CALLER: "...28, 29, 30!"
EMD: "Open his mouth wide. Do you see the piece of food?"
CALLER: "Yes! It's right there on his tongue!"
EMD: "Hook your finger and sweep it out! Do not push it down!"
CALLER: "I got it! A huge chunk of meat came out! (gasping sound)
He just took a huge breath! He's breathing!"
EMD: "Keep him flat on his back. Stay right by his side. The paramedics
are almost there. Keep his airway open!"
A restaurant caller reports that a dining companion suddenly stood up, is clutching their throat, is wheezing loudly, but is coughing forcefully between gasps. What is the mandatory MPDS instruction?
Why are abdominal thrusts (the Heimlich maneuver) strictly contraindicated in conscious choking infants under one year of age?
When a conscious adult choking victim suddenly loses consciousness during dispatch-directed abdominal thrusts, what is the mandatory clinical transition and airway safety rule?