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Clinical Practice Keywords Choking/Children/Back slap/Chest thrust/Abdominal thrust Practical procedures This article has been Emergency care double-blind peer reviewed Choking 2: foreign-body airway obstruction in infants and children

etween 2014 and 2016 there were Box 1. Severity of airway Author Phil Jevon is academy manager, 30 deaths from choking in infants obstruction Manor Hospital, Walsall Healthcare Trust. and children aged <14 years in BEngland and Wales (Office for Mild obstruction (effective cough) Abstract Foreign-body airway National Statistics, 2017). The causes of for- The infant/child: obstruction (FBAO) is a clinical eign-body airway obstruction (FBAO) are l Is crying/able to verbally respond emergency that may be life threatening. split equally between food and small to questions Nurses should be confident in assessing objects (ONS, 2017). l Has a loud cough the severity of airway obstruction, A quick response can prevent death l Is able to take a breath before delivering interventions to relieve the from choking, so nurses should be able to coughing and is fully responsive airway obstruction and knowing when recognise and respond to FBAO. Those to call for assistance. This article working with families should also ensure Severe obstruction (ineffective cough) outlines the procedure for assessing parents know how to prevent, recognise Typically the infant/child: and managing infants and children with and respond to it. l Is unable to vocalise an FBAO, which differs from managing l Is quiet airway obstruction in adults. Signs of FBAO l Has a silent cough Recognising the signs of FBAO in infants l Is unable to breathe Citation Jevon P (2018) Choking 2: and children is the key to early, effective l Shows signs of cyanosis and foreign-body airway obstruction in intervention. The context may provide decreasing levels of consciousness infants and children. Nursing Times important clues – for example, choking is Source: Maconochie et al (2017) [online]; 115: 1, 22-24. common at mealtimes, or a child may have been playing with small objects that easily fit into the mouth. The most common Other causes of airway obstruction in signs and symptoms of choking are: children – including laryngitis and epiglot- l A cough; titis – present with similar symptoms. The l Struggling to breathe or talk (cry in presence of a foreign body should be sus- infants); pected if the symptoms have a sudden l Gagging – the infant/child may go onset and there are no other systemic signs silent and hold or point to their throat. of illness such as pyrexia (Maconochie et al, If the obstruction is only partial, the 2017). If FBAO is suspected, it is important child may be able to vocalise/cry, cough to assess the severity by establishing and breathe (Maconochie et al, 2017). whether the infant/child has an effective or ineffective cough. In older children it is Fig 1. Paediatric choking algorithm useful to ask “are you choking?”; their response will help distinguish between a mild or severe obstructive airway (Box 1). Assess severity Treatment of FBAO in children The following procedures follow the Resus- citation Council (UK)’s guideline on the management of choking in infants (<1 year SEVERE MILD of age) and children (aged >1 year) (Macono- ineffective cough effective cough chie et al, 2017). An algorithm (Fig 1) pro- vides quick guidance on the appropriate procedure. Box 2 indicates the advice nurses can offer parents to prevent, or minimise CONSCIOUS UNCONSCIOUS ENCOURAGE COUGH the risk of, choking. Open airway 5 back blows Continue to check for 5 breaths 5 thrusts (chest thrusts deterioration to ineffective Start CPR for infants, abdominal cough or until obstruction is Mild airway obstruction (effective thrusts for children relieved aged >1 year) cough) in infants and children Coughing generates high and sustained CPR = cardiopulmonary resuscitation. airway pressures, and may expel a foreign Source: Macononchie et al (2017) body, so it is important to encourage the

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Fig 2. Back slaps in infants Fig 3. Chest thrust in infants

child to cough. Children with an effective shoulder blades (Fig 2). Following l Locate the ‘landmark’ for chest cough will be able to cry or verbally each back blow, check to see whether compressions – this is the lower respond to questions. In these situations, it has relieved the obstruction. sternum approximately a finger-width no external manoeuvres – such as back If back blows fail to dislodge the object above the xiphisternum; blows – are needed but close observation is and the infant is still conscious, deliver up l Perform up to five chest thrusts – these required until the infant/child improves, to five chest thrusts (Fig 3): are like chest compressions, but as severe airway obstruction may develop. l Turn the infant supine with head in a sharper in nature and delivered at a downwards position, using your arm to slower rate; Severe airway obstruction support the infant’s back and your l Following each chest thrust, check to (ineffective cough) in infants (<1 year) hand to support the head. Your thigh see whether the obstruction has been If the infant shows signs of severe airway can provide additional support; dislodged; obstruction: l If the obstruction remains, continue l Call for help/pull the emergency buzzer Box 2. Prevention of choking alternating up to five back blows with immediately; in infants and children up to five chest thrusts. l Deliver up to five back blows (slaps) using the following procedure: Nurses should advise parents to: Severe airway obstruction l Place the infant in a prone position l Always cut up food: infants and (ineffective cough) in children (>1 year) (usually over the lap) with the head young children can choke on If a child shows signs of severe airway downwards to enable gravity to help small, sticky or slippery foods obstruction: remove the foreign body (Fig 2); l Keep small objects out of reach: l Call for help/pull the emergency l Stabilise the infant’s (floppy) head: infants and small children examine buzzer immediately; place the thumb of one hand at the objects by putting them in their l Deliver up to five back blows angle of the lower jaw and one or mouths. Ensure small toys/objects (slaps) (Fig 4): two fingers on the opposite side of such as building bricks, button l Position the child with their head the jaw (take care not to compress batteries, coins and marbles are down (a small child may be placed the soft tissues under the infant’s stored out of reach over the lap, as described above). If jaw, as this could exacerbate the l Sit children down to eat this is not feasible, support the child obstruction of the airway) (Fig 2); l Always supervise infants and into the leaning-forward position l Deliver up to five sharp back blows young children recommended for adults (Fig 5); l  (slaps) with the heel of one hand in Source: Bit.ly/ChokingPrevention Deliver up to five sharp back blows

PETER LAMB PETER the middle of the back between the (slaps) with the heel of one hand in

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Fig 4. Back slaps in children Fig 5. Abdominal thrusts

the middle of the back between the l If the obstruction remains, continue Aftercare shoulder blades (Fig 4). Following alternating up to five back blows with After successful treatment for a FBAO, the each back blow, check to see whether up to five abdominal thrusts. foreign body may still be present in the air- the obstruction has been dislodged. ways and can cause complications. Advise If back blows fail to dislodge the object Management of the unconscious parents/carers that they should seek med- and the child is still conscious, deliver up infant/child ical advice if the infant/child has dysphagia to five abdominal thrusts using the fol- l If the infant/child loses consciousness, or a persistent cough, or complains of lowing procedure (Fig 5): carefully support them to a flat surface; having something stuck in their throat. l Position yourself behind the child l Summon help if it is still not available As chest/abdominal thrusts and chest either standing or kneeling. Place your (do not leave the infant/child); compressions can cause serious internal arms under the child’s arms; l Open the infant’s/child’s mouth. If an injury, patients must be examined for inju- l Place a clenched fist between the obvious object is seen, attempt to ries after these interventions have been umbilicus and xiphisternum; remove it with a single finger sweep. performed (Perkins et al, 2017). NT l Hold the clenched fist with your other Blind or repeated finger sweeps are not hand; pull sharply inwards and upwards; recommended because the object could References Maconochie I et al (2017) Paediatric Basic Life l  Deliver up to five abdominal thrusts. be pushed deeper into the pharynx; Support. London: Resuscitation Council (UK). Following each abdominal thrust, l Open the airway and attempt five Bit.ly/RCUKPaediatricChoking check to see whether the obstruction ventilations. Determine the Office for National Statistics (2017) Number of Choking Deaths by Place of Occurrence and Age has been dislodged; effectiveness of each ventilation – if the registered in England and Wales, 2014 to2016. l Take care not to apply pressure to the chest fails to rise, reposition the head; Bit.ly/Choking2016 xiphoid process or the lower rib cage as l If the infant/child remains Perkins G et al (2017) Adult Basic Life Support and this may cause abdominal trauma; unresponsive, commence chest Automated External Defibrillation. Bit.ly/RCUK ChokingResus compressions immediately. It is Professional responsibilities advised for a lone rescuer to perform cardiopulmonary resuscitation for CLINICAL Choking series These procedures should be undertaken one minute before summoning SERIES only after approved training, supervised assistance; Part 1: Foreign-body airway practice and competency assessment, l Before repeating ventilations, check the obstruction in adults Dec 2018 and carried out in accordance with local mouth for the presence of an object and Part 2: Foreign-body airway obstruction policies and protocols. remove it if this is possible (see above) in infants and children Jan 2019

PETER LAMB PETER (Maconochie et al, 2017).

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