Understanding the Universal Choking Signal and How to Respond

Choking, or foreign body airway obstruction (FBAO), is a frightening event that can quickly become life-threatening. Knowing how to recognize the signs of choking and how to respond effectively can save a life. The universal distress signal for choking is a crucial indicator that someone needs immediate assistance.

Recognizing the Universal Choking Signal

The universal distress signal for choking is grabbing the throat with one or both hands. This instinctive gesture is a clear sign that a person's airway may be completely or partially blocked, and they are in need of help. A person who is choking typically has a panicked, confused, or surprised facial expression. They may also exhibit other signs, including:

Inability to speak
Distress in breathing or unusually noisy, squeaking breaths
Weak or forceful cough
Flushed appearance, comprised of pallor and subsequent cyanosis (bluish discoloration)
Blue or dusky discoloration of the skin, lips, and nails

It's important to note that if the person is coughing forcefully and able to speak, DO NOT perform first aid, as a strong cough can dislodge the object on its own. Encourage the person to keep coughing, but continue to observe them.

The Urgency of Choking

A complete blockage of the airway is an urgent medical emergency. A partial obstruction can quickly become life threatening if the person loses the ability to breathe in and out sufficiently. Without oxygen, permanent brain damage can occur in as little as 4 minutes. Rapid first aid for choking can save a life.

FBAO is the 4th leading cause of unintentional death and a leading cause of accidental deaths in children younger than age 16, according to the National Safety Council-with 5051 documented deaths in 2015.

Causes and Risk Factors of Choking

Choking can result from both food and non-food items, leading to varying degrees of asphyxiation or oxygen deprivation. Food is the most common precipitant among children who receive treatment for nonfatal choking, responsible for 59.5% of cases, followed by non-food items, such as coins, marbles, balloons, and paper, with 31.4%. The cause is unknown in 9.1% of cases.

Round foods are more likely to cause fatal choking in children, with hotdogs being the most common, followed by candy, nuts, and grapes. Among non-food items, latex balloons are reportedly the leading cause of fatal choking events among children. In adults, autopsy results from 200 choking victims showed meat, fish, and sausage to be responsible for death in 71% of cases, followed by bread and bread products (12%) and fruits and vegetables (7%).

Major risk factors for choking include neurological disorders, dysphagia, and dental problems such as having few or no teeth, unstable prostheses, or unsuitable orthodontic appliances. Conditions associated with a higher risk of choking include Alzheimer disease, parkinsonism, prior stroke, intellectual or developmental disability, poor dentition, intoxication, dysphagia along with psychotropic medications, and advanced age.

Responding to a Choking Adult or Child (Over 1 Year Old)

If you encounter someone who is showing the universal choking sign and is unable to cough or speak, take the following steps:

Ask: "Are you choking?" "Can you speak?"
Stand behind the person. Place one foot between their feet, bending your knees slightly for stability. If a person is in a wheelchair, give abdominal thrusts as usual but you may need to kneel behind the wheelchair.
Wrap your arms around the person's waist.
Make a fist with one hand and place it slightly above their navel, well below the breastbone.
Grasp your fist with your other hand.
Give 5 quick, upward thrusts into the abdomen. The motion is up and inward, not just inward.
Check their mouth after each thrust. If you see the object, remove it only if you can grasp it easily.
Repeat until the object is dislodged or the person becomes unconscious.

Modifications for Pregnant Women or Obese Individuals:

Abdominal thrusts may not be feasible in patients who are pregnant or morbidly obese, but sternal thrusts may be performed. Place your hands on the lower half of the breastbone, just like you would for CPR chest compressions.

If the Person Becomes Unconscious:

Carefully lower them to the ground.
Call 911 if you haven’t already done so.
Begin CPR immediately, starting with chest compressions.
Before giving rescue breaths, look in their mouth for the object.

Responding to a Choking Infant (Under 1 Year Old)

For infants younger than 1 year, abdominal thrusts should not be performed as their livers are injury-prone. Instead, use the following technique:

Hold the infant face down over your forearm, supporting their jaw and chest. Position your forearm in a way that the infant’s head is lower than the chest.
Give 5 firm back blows between the shoulder blades using the heel of your hand.
Turn the infant face up on your other forearm, supporting their head.
Give 5 chest thrusts using two fingers in the center of the breastbone, compressing about 1.5 inches.
Repeat the sequence of back blows and chest thrusts until the object is dislodged or the infant becomes unresponsive.

If the Infant Becomes Unconscious:

Check the mouth for the obstruction.
Give two rescue breaths. Tilt the head back and lift the chin. Create a complete seal over the baby’s mouth and nose.
If the chest does not rise, give 30 chest compressions. Push about 1½ inches deep with fast compressions of about 100 per minute.
If the chest rises, check for breathing.

Self-Administering the Heimlich Maneuver

If you are choking and alone, call 9-1-1 using a landline or a GPS-enabled mobile phone. Give yourself abdominal thrusts, using your hands, just as if you were giving abdominal thrusts to another person. Alternatively, bend over and press your abdomen against any firm object, such as the back of a chair or a railing.

Common Mistakes to Avoid

Many well-meaning people make critical errors during choking emergencies. Here are the mistakes that can worsen the situation:

Using abdominal thrusts on someone who can still cough effectively. If they’re coughing forcefully, let them continue. Intervention might turn a partial blockage into a complete one.
Improper hand placement for thrusts. Too high (on the chest) can break ribs. Too low (on the abdomen) can damage internal organs. The sweet spot is just above the navel, below the breastbone.
Blind finger sweeps. Only remove objects you can clearly see and easily grasp. Fishing around blindly often pushes objects deeper into the throat.
Giving up too quickly. Continue the algorithm until help arrives or the situation changes. People have recovered after several minutes of intervention.
Forgetting to call for help. Successfully clearing someone’s airway doesn’t end your responsibility. The person should receive medical attention even if they seem fine.

The Importance of Training and Certification

Reading about choking first aid gives you knowledge, but hands-on practice builds the muscle memory you need during real emergencies. Practice scenarios help you understand how much force to use, proper hand placement, and how to adjust your technique for different body sizes.

Consider taking a certified course in first aid, CPR, and the Heimlich maneuver. These courses provide valuable hands-on training and can equip you with the skills and confidence to respond effectively in a choking emergency. Many workplaces, fitness professionals, and schools now require basic life-saving skills like the Heimlich Maneuver to ensure a safer environment for everyone.

After the Choking Incident

Following a choking experience, it is easy to assume a person is okay. However, any instance of choking, even when consciousness is never lost, could still result in serious medical complications. For example, aspiration may have occurred, which could lead to the buildup of fluid and bacteria in the lungs. Following any choking instance, see a health care professional for a full evaluation.

Preventing Choking

Caregivers can help prevent choking in infants, children, adults, and seniors by following a few choking safety tips:

Avoid Giving Small Children Small Toys or Those With Removable Parts That May Become a Choking Hazard
Check for Dietary Changes Prior to Mealtime
Use Thickened Liquids as Ordered
Don’t Try to Give a Person Too Much at Once
Avoid Distractions
Watch for Changes in Facial Hue
Avoid Using Straws
Avoid Foods That Are Difficult to Chew
Check Denture Placement Before Meals

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