1. Choking: HCA Education Continuing Care
Alena Thompson, RN, BScN Reviewed by Professional Practice Dept. Adaptations by Berni Baer RN GNC(c), Education Coordinator – St. Joseph’s Auxiliary Hospital Aug 9, 2016

2. Who do we help?
WE HELP ANY ONE WHO IS CHOKING i.e. Resident Client Patient Visitor Co-worker
i.e. If a patient on palliative care is choking, we help them, even with a GOA of C2

3. Signs of poor air exchange and difficulty breathing
Mild Airway Obstruction – signs:
Good air exchange
Can cough forcefully
May wheeze between coughs

4. How can you help the Resident who has mild airway obstruction?
Rescuer Actions:
Encourage the victim to continue spontaneous coughing and breathing efforts
Do not interfere with the residents efforts to cough up what they are choking on (ie. Do not slap them on the back, give a drink of water, etc.)
Stay with the resident and monitor their condition.
If mild airway obstruction persists, call CODE BLUE.

5. Signs of poor air exchange and difficulty breathing
Severe Airway Obstruction – signs:
Poor or no air exchange
High pitched noise while inhaling or no noise at all
Increased difficulty breathing
Weak ineffective cough or ‘silent’ cough
mouth opening and closing repeatedly as if they are trying to speak but no sound.  Think “guppy”

6. Signs of poor air exchange and difficulty breathing
Severe Airway Obstruction - signs: (continued)
Cyanosis (turning blue)
Unable to speak
May show the universal choking sign (clutch neck with both hands)
Tell a co-worker to call Code Blue.
Clipart:

7. Does the resident with Severe Airway Obstruction need your help?
Rescuer Actions:
Ask the resident if she/he is choking:
If yes, begin abdominal thrusts.
If no, stay close and allow them to try to get it out themselves.
If they are showing signs of severe airway obstruction but are unable to confirm or deny that they are choking, begin abdominal thrusts

8. How to do abdominal thrusts
Stand or kneel behind the resident
Wrap your arms around their waist
Locate their navel (belly button)
Make a fist with one hand and place it thumb side inward between the navel and breastbone
Grasp fist with other hand and press into abdomen with QUICK, FORCEFUL, UPWARD thrusts
QUICK, FORCEFUL, INWARD & UPWARD thrusts , as if trying to lift the person off the floor (but not forceful enough to lift them off the floor).
Click on link for a quick (1 min. 43 sec.) YouTube video on the Abdominal Thrust Maneuver
Demonstration of Abdominal Thrust:

9. Clipart: www.nursing411.org
Abdominal thrusts
Clipart:

10. How abdominal thrusts work
“When you choke on something, your body tries to clear your airway by coughing. Abdominal thrusts try to do the same thing with an artificial cough. The illustration on the right shows how an abdominal thrust creates a cough. An abdominal thrust pushes the diaphragm up towards the lungs very quickly - this forces air from the lungs up the airway and, hopefully, blows the object out. For the best effect, your fist has to be in the right place, the forearms off the abdomen and each thrust a strong and sudden movement.”
Source of quote & associated illustration 

11. Abdominal thrusts for person in a wheelchair
Push the wheelchair to a wall, lock the brakes, kneel in front of the victim and give abdominal thrusts from the front by pushing inward between the navel and breastbone.
Note: Abdominal thrusts are not as effective for a person in a seated position. Chest Thrusts are the preferred method.
Abdominal Thrusts may not produce enough force to expel the obstruction.
NOTE: With either the Chest Thrust or the Abdominal Thrust maneuvers it is important to remember to keep your head down, mouth closed. The object could come flying out if you are successful.

12. Abdominal thrusts - alternative method
Carefully lower the conscious resident to the floor and give abdominal thrusts
Straddle the person and put the heel of one hand mid abdomen, just below the ribcage. Place your other hand on top of this hand, interlocking your fingers, then press in and up in a smooth, forceful movement. Do this until object is expelled or the person becomes unconscious.
Abdominal Thrust on floor clip art from:

13. Chest thrusts
If victim is obese or rescuer cannot reach around to victim’s abdomen, chest thrusts can be done either standing or with the victim seated (ie. wheelchair):
From behind the person wrap your arms around their chest just under the armpits.
Make a fist with one hand and place it thumb side inward in the middle of the victims chest
Grasp fist with other hand and forcefully press inward in centre of chest.
Alternatively
Cross arms over one shoulder and under other arm to reach centre of chest and give chest thrusts
Emphasize that with this method you press straight back, just like with CPR chest compressions. You do not use the “J” motion of the abdominal thrust.
Clipart:

14. Chest thrusts for person in a wheelchair
Push the wheelchair against the wall, lock the brakes and kneel in front of the victim. Place the heel of one hand on the breast bone, at the nipple line, place the other hand on top of it and interlock the fingers. Forcefully press straight back.

15. Chest thrusts - alternative method
Carefully lower the conscious resident to the floor and give chest thrusts
Kneel at person’s side, place heel of one hand on chest at the nipple line. Place your other hand over it and interlock your fingers. Press straight down until object is expelled or the person becomes unconscious.
Chest Thrust on floor clip art from:

16. When to stop: Continue abdominal/chest thrusts until:
Object is expelled (comes out)
Resident collapses/becomes unresponsive

17. If resident collapses and becomes unresponsive
Carefully get them to the floor (if not already there)
Make sure a co-worker has called Code Blue & 911
Start CPR (if you’ve had the training)
NOTE: Abdominal thrusts will only work if the person is conscious.
Unconscious begin CPR
per Heart & Stroke Foundation of Canada BLS for Healthcare Providers Student Manual , page 53
If you are CPR trained move person to the floor and begin CPR.

18. Self-Help Abdominal Thrusts
If there are others nearby, get their attention. 
If you are alone do whatever you must do to get someone's attention. Call 911.
Do not allow anyone to slap you on the back.
If there is no one else to give you abdominal thrusts, give them to yourself (see illustrations on this slide).
If you are alone and you are choking, you must get help quickly - you will be unconscious within minutes. Do whatever you must do to get someone's attention.
Use either your hands or a piece of furniture, whichever works best (the back of a chair, a table or the edge of a counter).
Position yourself so the object is just above your pelvis. Press forcefully to produce an abdominal thrust - keep giving yourself thrusts until you can cough forcefully, breathe or speak.
Source of information 
You only have 2-3 minutes before you lose consciousness, and another 2-3 minutes before your heart stops.
Source of information & associated illustration 

19. Important note
Seek medical attention after abdominal/chest thrusts are performed. There could be injuries from this maneuver i.e. bruised/broken ribs; punctured liver; etc.

20. References
American Heart Association (2011). BLS for Healthcare Providers Student Manual. First Heart and Stroke Foundation of Canada Printing May 2011.
Covenant Health Policy VII-C-30:
Choking Prevention and Management

21. Time to practice
With a partner practice correct land marking and hand placement. DO NOT DO ACTUAL PERFORMANCE OF THE MANEUVER as it could injure your partner.