Foreign Body Management

Controversy exists as to the safest and most effective emergency maneuvers to use with a choking child. The American Heart Association specifically discourages two common maneuvers used with adult patients: (1) the Heimlich maneuver for patients younger than age 1, because of the potential for injury to abdominal organs, and (2) blind finger sweeps, because of the possibility of pushing the foreign body further into the airway. 4 Serious differences of opinion exist, but current recommendations rely on the back blow and chest thrust to clear an infant's airway.

CONSCIOUS CHILDREN A child who is choking but is able to maintain some ventilation or vocalization should be allowed to clear her or his own airway by coughing. Once a child cannot cough, vocalize, or breathe, a sequence of steps must be immediately instituted. Choking infants are treated with an alternating sequence of five back blows and five chest thrusts. With the infant's torso positioned prone and head down along the rescuer's arm, or the older child draped prone and head down across the rescuer's knees, five blows are delivered to the interscapular area. The infant is then repositioned supinely along the rescuer's arm, or the larger infant can be placed on the floor as for external cardiac compression, and five chest thrusts (cardiac compressions) are delivered. These are continued until the child's airway obstruction is relieved or the child becomes unconscious. In older children, the Heimlich maneuver is used, with the rescuer kneeling or standing behind the child. The clenched fist is placed at the level of the umbilicus, and firm upward thrusts are continued until the obstruction is cleared or the child becomes unconscious.

UNCONSCIOUS CHILDREN In all cases where a child becomes unconscious with the rescuer present, the rescuer should first attempt ventilation because the object may have become dislodged. If an obstruction is still present, then airway clearance maneuvers must be continued. For infants, the same sequence is used, but between each cycle of back blows and chest thrusts (the same technique as for CPR) an attempt at ventilation should be made. Before attempting a ventilation, the airway should be inspected to see whether an object is present. Only remove a visualized object, do not use blind finger sweeps. If the obstruction persists, the sequence is repeated. For children older than age 1, the Heimlich maneuver is performed with the child lying down and the rescuer straddling the child's thighs. Future investigation may well lead to revised recommendations.

The foregoing recommendations are directed primarily at a first responder who has neither access to, nor the skills to use, airway management equipment. For unconscious children in emergency departments, direct laryngoscopy, visualization, and removal of the foreign body with McGill forceps should be attempted rapidly. Until this equipment is ready, however, use the basic life support techniques.

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