CHOKING FROM A FOREIGN BODY AND

PAEDIATRIC BASIC LIFE SUPPORT

Choking from a foreign body
Despite preventative measures (eg making pen tops with holes in them),
children continue to die each year from airway obstruction due to FB impaction.
FB aspiration produces a sudden onset airway problem and must be
distinguished from other causes of airway obstruction (epiglottitis, bacterial
tracheitis see b Stridor: upper respiratory tract infections, which may be
worsened by the basic measures described below.
The majority of choking events in children are witnessed and occur during play
or whilst eating. FB airway obstruction is characterized by sudden onset of
respiratory distress associated with coughing, gagging or stridor
with no other signs of illness. If the child is coughing effectively (fully
responsive, loud cough, able to take a breath before coughing, crying or verbal
response to questions), encourage coughing and observe for the cough
becoming ineffective.

Conscious, but ineffective cough

If conscious with an ineffective cough, give 5 back blows. In the infant, support
in a head downwards prone position and in the child aim for a head down or
forward leaning position. Deliver 5 sharp back blows with the heel of one hand
centrally between the shoulder blades. If ineffective, turn to supine position and
give 5 chest thrusts to infants (using the same landmarks as for
cardiopulmonary resuscitation (CPR), but thrusts are sharper and delivered at a
slower rate) and abdominal thrusts to children > 1 year. Perform abdominal
thrusts from behind the child, placing your fist between the umbilicus and
xiphisternum, and grasping it with your other hand, then pulling sharply inwards
and upwards — repeat up to 5 times. Following chest or abdominal thrusts, if
the object has not been expelled and the victim is still conscious then repeat the
sequence of back blows and chest (for infant) or abdominal (for children)
thrusts.
Do not use abdominal thrusts for infants.
Unconscious from foreign body airway obstruction If a child with FB airway
obstruction is or becomes unconscious, place him on a flat surface, then open
the mouth and look for any obvious object. If one is seen, use a single fi nger
sweep to remove it. It may be possible to remove the FB with Magill’s forceps
under direct laryngoscopy. Do not
attempt blind or repeated fi nger sweeps. Open the airway and attempt 5 rescue
breaths. If a breath does not make the chest rise, reposition the head before
making the next attempt. If there is no response whilst
attempting the 5 rescue breaths, proceed to chest compression with ventilation
using a ratio of 15:2. Each time the airway is opened, check for a foreign body
and if visible, try to remove it .
If it appears that the obstruction has been relieved, open and check the airway.
If the child is not breathing, deliver rescue breaths. If initial measures prove
unsuccessful and the child is hypoxic, oxygenate via a surgical airway until
senior help arrives. Perform needle cricothyroidotomy in children aged <12
years, surgical cricothyroidotomy in older children.

Paediatric basic life support

Evaluate responsiveness
Check the child’s responsiveness — gently stimulate and ask loudly ‘are you
alright?’ Do not shake if you suspect cervical spine injury. If the child does not
respond, shout for help ± get someone to go for assistance.
Open airway
Open the airway by head tilt and chin lift. Desirable degrees of tilt are neutral <1
year and ‘sniffing the morning air’ > 1 year. Do not press on thensoft tissues
under the chin as this may block the airway. If it is still difficult to open the
airway, try a jaw thrust. If there is any suspicion that there may have been a
neck injury, instruct a second rescuer to manually immobilizemit, and use either
chin lift or jaw thrust alone. If this is unsuccessful, add the smallest amount of
head tilt needed to open the airway.

Check breathing
Whilst keeping the airway open, look listen and feel for breathing for 10sec. If
the child is not breathing or is making infrequent irregular breaths, carefully
remove any obvious obstruction, give 5 initial rescue breaths
(with the rescuer taking a breath between each rescue breath).
Rescue breaths
For children > 1 year , whilst maintaining head tilt and chin lift, give breaths
mouth to mouth, pinching off the nose. Blow steadily for 1–1.5sec watching for
the chest to rise. Take your mouth away, watch the chest fall
and repeat this sequence 5 times. For the infant (<1 year) ensure the neutral
position of the head and apply
chin lift. Give mouth to mouth and nose breaths, ensuring a good seal. Blow
steadily for 1–1.5sec watching for chest rise. Take your mouth away, watch the
chest fall and repeat this sequence 5 times.
Difficulty achieving an effective breath suggests airway obstruction. Open the
mouth and remove visible obstruction (no blind fi nger sweep), ensure
appropriate head tilt/chin lift and neck position. Try a jaw thrust if head
tilt/chin lift has not worked. Try up to 5 times to give effective breaths. If still
unsuccessful, move to chest compression.
Check pulse
Over the next 10sec check for signs of life: any movement, coughing or normal
breathing and check for a pulse (use carotid for > 1yr and brachial for those <1
year). If there are no signs of life and/or no pulse or pulse
<60/min with poor perfusion or you are unsure: start chest compression.
Chest compression
For infants , perform chest compressions (100–120/min) by placing both thumbs
flat side by side on the lower third of the sternum with the tips pointing towards
the infant’s head. Encircle the rib cage with tips of fingers
supporting the infant’s back. Press down with thumbs at least one third of the
depth of the chest.
In children > 1 year using the heel of one hand, compress the lower half of the
sternum by at least one-third of the depth of the chest at a rate of 100–120/min.
Use two hands if necessary to achieve the depth required.