Download Level of Evidence

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WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS
NOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is
a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name
and 30Jul03 as sample date format.
Worksheet Author:
Taskforce/Subcommittee: _X_BLS __ACLS __PEDS __ID
__PROAD
Gavin D Perkins MB ChB MRCP FIMC RCS(Ed)
__Other:
Author’s Home Resuscitation Council:
__AHA __ANZCOR __CLAR __ X ERC _ _HSFC
Date Submitted to Subcommittee:
__HSFC __RCSA ___IAHF ___Other:
30.7.04; revised 20 Aug 04; 27 Sep 04
STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of
current guideline.
Existing guideline, practice or training activity, or new guideline:
Existing guideline: Most resuscitation councils recommend one or more of the following: the Heimlich abdominal
thrusts, back blows, or chest thrusts. The level of evidence regarding any of these methods is weak, largely contained in
case reports, cadaver studies, small studies involving animals, or mechanical models. Unfortunately, implementation of a
randomized, prospective study to compare techniques for relief of FBAO in humans would be extremely difficult.
Mechanical models of choking have been unsatisfactory. Cadaver studies can provide excellent models of
unresponsive/unconscious victims, but they cannot replicate awake, responsive choking victims. Therefore, current
recommendations are based on a low level of evidence (LOE 5 to 8), with an emphasis on the need to simplify
information taught to the lay rescuer.
The Heimlich maneuver (also known as subdiaphragmatic abdominal thrusts or abdominal thrusts) is recommended for
lay rescuer relief of FBAO in responsive adult (>8 years of age) and child (1 to 8 years of age) victims in the United
States, Canada, and many other countries. It is not recommended for relief of FBAO in infants. The Heimlich maneuver
is also recommended by the AHA and several other resuscitation councils for use by healthcare providers for
unresponsive adult and child (but not infant) victims.
Some resuscitation councils (eg, the European Resuscitation Council) recommend that the rescuer provide up to 5 back
blows/slaps as the initial maneuver, with the back slaps delivered between the shoulder blades with the heel of the
rescuer’s hand. If back slaps fail, up to 5 abdominal thrusts are then attempted, and groups of back slaps and abdominal
thrusts are repeated. In countries such as Australia, back slaps and lateral chest thrusts are recommended for relief of
FBAO in adults.
The Heimlich abdominal thrusts elevate the diaphragm and increase airway pressure, forcing air from the lungs. This
may be sufficient to create an artificial cough and expel a foreign body from the airway. Successful relief of FBAO in
responsive victims has been reported in the lay press and in medical case studies. Abdominal thrusts, however, may
cause complications. For this reason, the Heimlich maneuver should never be performed unless it is necessary.
Reported complications of the Heimlich maneuver include damage to internal organs, such as rupture or laceration of
abdominal or thoracic viscera. In fact, victims who receive the Heimlich maneuver should be medically evaluated to rule
out any life-threatening complications. To minimize the possibility of complications, do not place your hands on the
xiphoid process of the sternum or on the lower margins of the rib cage. Your hands should be below this area but above
the navel and in the midline. Some complications may develop even if the Heimlich maneuver is performed correctly.
Regurgitation may occur as a result of abdominal thrusts and may be associated with aspiration.
Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed
guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of
patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital
discharge).
1) The back slap is feasible, safe and effective for the choking victim
2) The abdominal thrust (Heimlich manoeuvre) is feasible, safe and effective for treating the choking victim
3) The chest thrust is feasible, safe and effective for treating the choking victim
4) The finger sweep should be used in the unconscious patient with an obstructed airway if there is visible evidence of
fluid or solid material in the airway
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5) The obese choking victim should be treated by chest thrusts in preference to the abdominal thrust
6) The pregnant choking victim should be treated by chest thrusts in preference to the abdominal thrust
Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for
evidence.
PUBMED searched using following strategy: (Choking [Text Word] OR heimlich[Text Word] OR back blows[Text word])
AND ("airway obstruction/*therapy"[MeSH] OR Foreign body/*therapy[MeSH])
List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for
systematic reviews and Central Register of Controlled Trials [http://www.cochrane.org/], MEDLINE
[http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles, and books.
PUBMED, End-note, Cochrane
EMBASE
Hand search of references of journals and review articles
• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with
control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts
only? no abstract-only studies?)
Human studies
Letters / review articles not containing raw data or new data were excluded. Articles discussing airway obstruction below
the vocal cords were excluded
Peer reviewed manuscripts only were considered
Purely epidemiological studies were not included
• Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author
initials and date or Arabic numeral, e.g., “Cummins-1”). . If possible, please supply file of best references; EndNote 6+
required as reference manager using the ECC reference library.
PubMed search yielded 179 articles (27th September 04), Endnote library 74 (July). From reviewing abstracts of these
articles and reference lists 81 were selected for detailed review, of these, 59 were articles were identified as relevant.
There were no Cochrane meta-analyses
STEP 2: ASSESS THE QUALITY OF EACH STUDY
Step 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based
on study design and methodology.
Level of
Definitions
Evidence
(See manuscript for full details)
Level 1
Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Level 2
Randomized clinical trials with smaller or less significant treatment effects
Level 3
Prospective, controlled, non-randomized, cohort studies
Level 4
Historic, non-randomized, cohort or case-control studies
Level 5
Case series: patients compiled in serial fashion, lacking a control group
Level 6
Animal studies or mechanical model studies
Level 7
Extrapolations from existing data collected for other purposes, theoretical analyses
Level 8
Rational conjecture (common sense); common practices accepted before evidence-based guidelines
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Step 2B: Critically assess each article/source in terms of research design and methods.
Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide
an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a
Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code
(shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached
assessment form.
Component of
Study and
Rating
Design &
Methods
Excellent
Good
Highly
appropriate
sample or model,
randomized,
proper controls
AND
Outstanding
accuracy,
precision, and
data collection in
its class
Highly appropriate
sample or model,
randomized, proper
controls
OR
Outstanding accuracy,
precision, and data
collection in its class
A = Return of spontaneous circulation
B = Survival of event
Fair
Adequate,
design, but
possibly
biased
OR
Adequate
under the
circumstances
Poor
Small or clearly
biased population
or model
OR
Weakly defensible
in its class, limited
data or measures
C = Survival to hospital discharge
D = Intact neurological survival
Unsatisfactory
Anecdotal, no
controls, off
target endpoints
OR
Not defensible
in its class,
insufficient data
or measures
E = Other endpoint
Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?
DIRECTION of study
by results &
statistics:
Results
SUPPORT the proposal
NEUTRAL
OPPOSE the proposal
Outcome of proposed
guideline superior, to a
clinically important degree, to
current approaches
Outcome of proposed
guideline no different from
current approach
Outcome of proposed
guideline inferior to current
approach
Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/
opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair
quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation
marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them
from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary
endpoint of each study.
Supporting Evidence
1) The back slap is feasible, safe and effective for the choking victim
2) The abdominal thrust/Heimlich manoeuvre is feasible, safe and effective for treating the choking victim
3) The chest thrust is feasible, safe and effective for treating the choking victim
4) The finger sweep should be used in the unconscious patient with an obstructed airway if there is visible evidence of
fluid or solid material in the airway
5) The obese choking victim should be treated by chest thrusts in preference to the abdominal thrust
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6) The pregnant choking victim should be treated by chest thrusts in preference to the abdominal thrust
Quality of Evidence
Excelle
nt
Good
Fair
Langhelle
2000*E3
1
2
(Heimlich et
al. 1975) E2
(Ruben et al.
1978)E1-3
{Boussuges, 1985
#12489}E2
(Redding 1979)E1-4
(Heimlich et al. 1975) E2
(Vilke et al. 2004) E1-4
3
4
5
Level of Evidence
A = Return of spontaneous circulation C = Survival to hospital discharge
B = Survival of event
D = Intact neurological survival
Note: numbers indicate which hypothesis is associated with the citation
6
7
8
E = Other endpoint
* = cadaver study
Neutral or Opposing Evidence
1) The back slap is feasible, safe and effective for the choking victim
2) The abdominal thrust/Heimlich manoeuvre is feasible, safe and effective for treating the choking victim
3) The chest thrust is feasible, safe and effective for treating the choking victim
4) The finger sweep should be used in the unconscious patient with an obstructed airway if there is visible evidence of
fluid or solid material in the airway
5) The obese choking victim should be treated by chest thrusts in preference to the abdominal thrust
Quality of Evidence
6) The pregnant choking victim should be treated by chest thrusts in preference to the abdominal thrust
Excelle
nt
Good
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Fair
1
2
3
4
5
Level of Evidence
A = Return of spontaneous circulation C = Survival to hospital discharge
B = Survival of event
D = Intact neurological survival
Note: numbers indicate which hypothesis is associated with the citation
6
(Ruben et al.
1961) E4
(Elam et al.
1960) E4
(Cunningha
m 2002) E4
7
8
E = Other endpoint
STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions.
CLASS
CLINICAL DEFINITION
REQUIRED LEVEL OF EVIDENCE
Class I
• Always acceptable, safe
• One or more Level 1 studies are present
Definitely recommended.
• Definitely useful
(with rare
Definitive,
• Proven in both efficacy &
exceptions)
excellent evidence provides
effectiveness
• Study results consistently positive and
support.
• Must be used in the intended
compelling
manner for
proper clinical indications.
Class II:
• Safe, acceptable
• Most evidence is positive
Acceptable and useful
• Clinically useful
• Level 1 studies are absent, or inconsistent,
• Not yet confirmed definitively
or lack
power
• No evidence of harm
• Class IIa: Acceptable and
• Safe, acceptable
• Generally higher levels of evidence
useful
• Clinically useful
• Results are consistently positive
Good evidence provides support • Considered treatments of choice
• Class IIb: Acceptable and
• Safe, acceptable
• Generally lower or intermediate levels of
useful
• Clinically useful
evidence
Fair evidence provides support
• Considered optional or alternative • Generally, but not consistently, positive
treatments
results
Class III:
Not acceptable, not useful, may
be
harmful
Indeterminate
• Unacceptable
• Not useful clinically
• May be harmful.
• No positive high level data
• Some studies suggest or confirm harm.
• Research just getting started.
• Continuing area of research
• No recommendations until
further research
• Minimal evidence is available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline
Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class
IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc.
Indicate if this is a __Condition or __Intervention
Final Class of recommendation: __Class I-Definitely Recommended __Class IIa-Acceptable & Useful; good
evidence
__Class IIb-Acceptable & Useful; fair evidence
__Class III – Not Useful; may be harmful
__Indeterminate-minimal evidence or inconsistent
1) The back slap is feasible, safe and effective for the adult choking victim (Class IIb, level of evidence 5)
2) The abdominal thrust/Heimlich manoeuvre is feasible, safe and effective for treating the choking victim
(Indeterminate, level of evidence 5)
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3) The chest thrust is feasible, safe and effective for treating the choking victim (Class IIb, level of evidence 5)
4) The finger sweep should be used in the unconscious patient with an obstructed airway if there is visible evidence of
fluid or solid material in the airway (Indeterminate, level of evidence 5)
5) The obese choking victim can be treated by chest thrusts or the abdominal thrust (Class Indeterminate, level of
evidence 6)
6) The pregnant choking victim should be treated by chest thrusts in preference to the abdominal thrust (Indeterminate,
level of evidence 7)
REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background,
clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List
any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline
proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or
longstanding disagreements with an individual.
I am a Lecturer in respiratory and critical medicine. I have recently completed a 3 year post as a postgraduate research
fellow. I am in the process of preparing a doctoral thesis for the award of MD.
I am a member of the ERC BLS/AED International Course Committee. I am a member of the Resuscitation Council
(UK) ILS and ALS Committees.
I have no conflict of interest to declare.
REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the
rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches”
refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong,
but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal
or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results
from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have
made, separate from the evidence. For example, you believe evidence-supported interventions should be limited to in-hospital use because you think
proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment.
The scientific literature surrounding the management of the victim with FBAO is predominantly anecdotal or based on
experiments on anaethetised volunteers or cadavers. There are no randomized controlled clinical trials comparing
techniques, nor are any likely to be performed in the future. The precise sequences for the management of choking
have been hotly debated over the last 30 years.
Back-slaps:
There are several anecdotal case reports where the use of a back slap has been reported as an effective treatment for
FBAO(Ingalls 1979; Redding 1979; Vilke et al. 2004). Using anaethetised, human volunteers, (Day et al. 1982) reported
that back blows generated lower alveolar pressures (11.5 vs 21.25 mm Hg) of shorter duration (0.01 sec vs 0.7 sec)
than abdominal thrusts. Back blows also caused upward acceleration of neck and upper back that the authors
postulated would propel a foreign body towards the glottis, potentially worsening airway obstruction. Others have
challenged the interpretation of these results. In contrast, in anaethetised, paralysed volunteers Ruben (Ruben et al.
1978) reports higher airway pressures with the back slap and chest thrust than the Heimlich maneuver.
(Heimlich 1982) reports the use of back-blows and chest thrusts causes complications and deaths in a special
commentary quoting 20 references to support this statement. Few of these references had been published in peerreviewed journals and I was unable to trace any evidence to support this statement. On balance, my assessment of the
evidence available supports the hypothesis that the back slap is feasible, safe and effective in the choking victim.
Heimlich manoeuvre / abdominal thrusts
The greatest number of anecdotal reports support the use of the Heimlich manoeuvre (Heimlich 1975; Heimlich et al.
1975; Redding 1979; Craig 1980; Heimlich 1982; Nelson 1989; Fioritti et al. 1997; {Boussuges, 1985 #12489};
Lapostolle et al. 2000; Vilke et al. 2004). Some of these reports come from the inventor of the technique or its
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advocates. The technique was widely advocated and the confounding influence of publication bias tending to favour
successful reports should be considered when reviewing this evidence. There are also a substantial number of
anecdotal reports of serious harm (life threatening or fatal) occurring whilst performing the technique in both the first aid
provider (Feldman et al. 1986) and the victim (Visintine et al. 1975; Agia et al. 1979; Rich 1980; Chapman et al. 1983;
Croom 1983; Roehm et al. 1983; Haynes et al. 1984; Ujjin et al. 1984; Barker et al. 1985; Kirshner et al. 1985; Meredith
et al. 1986; Razaboni et al. 1986; Valero 1986; Cowan et al. 1987; Orlowski 1987; Fink et al. 1989; van der Ham et al.
1990; Dupre et al. 1993; Patterson et al. 1993; Bintz et al. 1996; Cumberbatch et al. 1996; Majumdar et al. 1998; Nowitz
et al. 1998; Anderson et al. 1999; Tung et al. 2001; Wolf 2001; Ayerdi et al. 2002; Fearing et al. 2002; Mack et al. 2002;
Gallardo et al. 2003; Olenchock et al. 2004). There is insufficient evidence to support the hypothesis that complications
only arise when the technique is performed incorrectly (Heimlich 1982). It is not possible to determine the incidence of
these complications compared to the number of times the procedure has been administered. Publication bias is likely to
contribute to the higher number of reports of complications than uncomplicated uses of the technique.
Conclusion: There is anecdotal and laboratory evidence that abdominal thrusts are feasible and effective for treating
FBAO in conscious and unconscious victims. There are a substantial number of anecdotal reports indicating that this
technique is not safe and has been associated with severe and fatal complications. On balance from the evidence
available, my view is that because of the potential for harm from this technique, it should be considered second line to
back slaps in the conscious victim. There are no clinical trials to support this statement. The laboratory evidence favors
chest thrusts in the unconscious FBAO victim.
Chest thrust
There are some anecdotal reports supporting the use of the chest thrust to clear FBAO(Redding 1979). In a study using
anaethetised patients in both a sitting and standing position, Guildner et al (1976) reported higher peak flow rate,
expelled volume and peak pressures following low chest thrusts (2-3 fingers above the xiphoid) compared to mid chest
thrusts and abdominal thrusts. This relationship was true in both the sitting and standing positions. Langhelle et al.
(2000) reported higher mean peak airway pressures with chest thrusts compared to abdominal thrusts 40.8+/-16.4
cmH2O versus 26.4+/-19.8 cmH2O, respectively (P=0.005, 95% confidence interval for the mean difference 5.3-23.4
cmH2O).
Conclusion: There is anecdotal and laboratory evidence that chest thrusts are feasible safe and effective for the
management of the FBAO. There are no clinical trials comparing the chest thrust to other techniques. The laboratory
evidence favors chest thrusts in the unconscious FBAO victim.
Finger sweep
There are a few anecdotal reports where the finger sweep has been used successfully to clear the obstructed
airway(Redding 1979; Brauner 1987;; Vilke et al. 2004). There are also reports of the technique causing damage to the
pharyngeal wall in a child(Hartrey et al. 1995). The layman’s understanding of the indications for the finger sweep in a
victim with FBAO tested in a questionnaire survey of sports coaches is poor(Cunningham 2002). Anecdotal reports of
rescuers putting their thumbs in a victims mouth to open the airway indicates that they are frequently bitten by the
victim(Elam 1960; Ruben et al. 1961).
In my opinion, the finger sweep should only be used in the unconscious victim with an obstructed airway after other
techniques to position and clear the airway have failed.
Obesity
The human cadaver study by (Langhelle et al. 2000) included two thin and one obese patient. No airway pressure
could be generated in the thin individuals after an abdominal thrust. Peak airway pressure in the obese patient was
greater for abdominal thrusts than chest thrust. One case report in an obese patient during anaesthesia suggests that
the abdominal thrust can generate high airway pressures. In this report, the legs of the patient were raised on to the
abdomen (simulating an abdominal thrust) and the ventilator mounting was noted to pop off. The author’s hypothesis
that this was due to increased airway pressure associated with the manoeuvre. Whilst there is no un-equivocal
evidence that one technique is superior to the other in the obese patient, the data available to date contradicts the
current guidance of performing a chest thrust rather than abdominal thrust in these patients.
Pregnancy
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There are no studies to guide the management of FBAO in the pregnant patient. Rational conjecture suggests that the
Heimlich manoeuvre should be contraindicated.
Conscious versus unconscious
There is anecdotal evidence supporting the efficacy of back slaps, chest thrusts and abdominal thrusts in conscious and
un-conscious victims (see table).
As discussed above, the balance of experimental evidence in anaethetised{Guildner, 1976 #247} and recently
deceased patients{Langhelle, 2000 #237} favors the use of the chest thrust over the abdominal thrust in unconscious
victims.
There is indirect evidence that placing digits in the mouth of conscious or semi-conscious patients is associated with
injury to the rescuer{Elam, 1960 #277;Ruben, 1961 #172}
Finger sweep
Back slaps
Chest compression
Abdominal thrusts
Conscious
{Brauner, 1987 #13465}
{Hartrey, 1995 #252;Ingalls, 1979 #12486}
{Heimlich, 1975 #660;Heimlich, 1976
#13500;Lapostolle, 2000 #12482;Nelson, 1989
#13467}
Unconscious
{Skulberg, 1992 #746}
{Penny, 1983 #12491}
The Redding series (1979) reports that 34 of 208 victims were unconscious or semi-conscious but does not differentiate
as to which treatments were used in which group. The Vilke study (2004) does not differentiate conscious levels.
Lay versus healthcare professional (#*)
There is evidence to suggest that back slaps, chest thrusts and abdominal thrusts have been successfully executed by
both lay persons and healthcare professionals. There is no evidence to suggest that one technique is superior to the
other in the hands of either group.
There is evidence of poor recall of choking procedures in lay persons (multiple choice examination paper of sports
coaches investigating management of partial airway obstruction){Cunningham, 2002 #10223}.
Finger sweep
Back slaps
Chest compression
Abdominal thrusts
Lay person
{Redding, 1979 #246;Vilke, 2004 #13486}
{Hartrey, 1995 #252;Redding, 1979 #246;Vilke,
2004 #13486}
{Redding, 1979 #246}
{Heimlich, 1975 #660;Heimlich, 1975
#665;Heimlich, 1976 #13500;Lapostolle, 2000
#12482;Nelson, 1989 #13467;Redding, 1979
#246;Vilke, 2004 #13486}
Healthcare Professional
{Redding, 1979 #246;Brauner, 1987
#13465}
{Ingalls, 1979 #12486;Redding, 1979
#246}
{Skulberg, 1992 #746} {Redding, 1979
#246}
{Craig, 1980 #13488;Fioritti, 1997 #699}
{Heimlich, 1975 #660;Heimlich, 1975
#665;Heimlich, 1976 #13500} {Redding,
1979 #246;Penny, 1983 #12491}
# The Redding study does not explicitly state whether reports were received from healthcare professionals or lay
persons. In view of the large number of reported uses I have assumed that the data was reported from both sources.
 The Vilke (2004) article does not distinguish between successful and unsuccessful applications
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Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by
the person assigned to write this section. Use extra pages if necessary.
DRAFT CONSENSUS ON SCIENCE
Conscious Victim
Evidence from numerous case reports demonstrate the feasibility and effectiveness of back blows
(Ingalls 1979; Redding 1979; Vilke et al. 2004), abdominal thrusts (Heimlich 1975; Heimlich et al.
1975; Redding 1979; Craig 1980; Heimlich 1982; Nelson 1989; Fioritti et al. 1997; {Boussuges, 1985
#12489}; Lapostolle et al. 2000; Vilke et al. 2004) and chest thrusts (Redding 1979) for the treatment
of FBAO in conscious adults and children aged > 1 year
Evidence from 6 case reports (LOE 5) (Brauner 1987; Heimlich 1976; Heimlich 1982; Norwitz 1998;
Skulberg 1992; Westphal 1997) and one large case series of 229 choking episodes (LOE 5)
(Redding 1979) report failure to relieve airway obstruction in approximately 50% of occasions when a
single technique is used. Success increased when combinations of back blows, abdominal and
chest thrusts were used.
Unconscious Victim
Two case reports (LOE 5) specifically describe successful application of the chest thrust (Skulberg
1992) and abdominal thrust (Penny, 1983) in an unconscious choking victim. Evidence from 1
randomised controlled study in cadavers (Langhelle 2000) and 2 other prospective studies in
anaethetised volunteers (LOE 6)(Guildner 1976, Ruben 1978) indicate that sustained higher airway
pressures can be generated using the chest thrust compared to the abdominal thrust in the
unconscious patient.
Evidence from 3 case series (LOE 5) (Redding 1979; Brauner 1987; Vilke et al. 2004) report the
finger sweep as effective for relieving FBAO in adults and children age>1. One case report
describes pharyngeal and tonsillar injury following a blind finger sweep in a 9 week old child (LOE 5)(
Hartrey et al. 1995). Two case series describing airway opening maneuvers which involved inserting
digits into the mouth report a high frequency of the digit being bitten (LOE 7)( Elam 1960; Ruben et
al. 1961). A questionnaire of survey 86 first aiders demonstrates poor understanding of the
indications for the finger sweep (LOE 7)(Cunningham 2002).
Special circumstances
Two anecdotal reports (LOE 5)(Langhelle 2000, Stix 2001) suggest that the abdominal thrust may be
more effective for relieving FBAO in the obese victim with FBAO
There are no studies investigating the treatment of FBAO in the pregnant victim
Abdominal Thrust Safety
There are numerous case reports of life-threatening complications from administering Heimlich
abdominal thrusts: 11 case reports of gastric rupture – Gallardo(03), Ayerdi(02), Tung(01),
Majumbra(98),.Bintz(96), Dupre(93), van der Ham(90), Cowan(87), Barker(83), Croom(83),
Visintine(75); three cases of aortic thrombosis – Mack(02), Kirschner(85) and Roehm(83); cervical
artery dissection - Rakotoharinandrasana(03), intraabdominal injuries – Wolf(01),Valero(86)
Ujjin(84); extensive surgical emphysema, pneumomediastinum and pneumopericardium –
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Nowitz(98), Rich(80), Agia(79); rupture of the esophagus – Meridith(86); ruptured aortic valve cusp –
Chapman(83); and vomiting with aspiration – Orlowski(87).
DRAFT TREATMENT RECOMMENDATIONS
A combination of chest thrusts, back blows and/or abdominal thrusts are feasible and effective for
relieving foreign body airway obstructions (FBAO) in conscious adults and children older >1-year of
age (LOE 5)
The chest thrust should be used to treat the unconscious adult patient with FBAO (LOE 5)
The finger sweep can be used in the unconscious patient with an obstructed airway if there is solid
material visible in the airway (LOE 5)There is insufficient evidence for a treatment recommendation
for an obese or pregnant patient with FBAO Patients treated with abdominal thrusts should be
examined for injury by an experienced physician (LOE 5)
Attachments:
 Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be
provided in annotated format. This will include the article abstract (if available) and any notes you would like to
make providing specific comments on the quality, methodology and/or conclusions of the study.
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Citation List
Citation Marker
(Agia et al. 1979)
Full Citation*
Agia, G. A. and D. J. Hurst (1979). "Pneumomediastinum following the Heimlich
maneuver." Jacep 8(11): 473-5.
No abstract supplied
Level 5(unsatisfactory – single case)
Opposes H2
(Anderson et al. 1999)
Anderson, S. and D. Buggy (1999). "Prolonged pharyngeal obstruction after the Heimlich
manoeuvre [letter]." Anaesthesia 54(3): 308-309.
No abstract supplied
Level 5 (unsatisfactory – single case)
Opposes H2
Failure of Heimlich to remove object from oropharynx. Patient presented 10 weeks later
with dyphagia
(Ayerdi et al. 2002)
Ayerdi, J., S. K. Gupta, et al. (2002). "Acute abdominal aortic thrombosis following the
Heimlich maneuver." Cardiovasc Surg 10(2): 154-6.
Abstract: Complications from the Heimlich maneuver are relatively infrequent. Two fatal
cases of abdominal aortic thrombosis have been reported following this technique. We
report on the first patient that suffered an acute thrombosis of the abdominal aorta and
survived. Prompt recognition of this complication provides the only hope of survival from
this rare and catastrophic complication.
Level 5(unsatisfactory – single case)
Opposes H2
(Barker et al. 1985)
Barker, S. J. and T. Karagianes (1985). "Gastric barotrauma: a case report and theoretical
considerations." Anesth Analg 64(10): 1026-8.
No abstract supplied
Level 5 (unsatisfactory)
Opposes H2
Gastric rupture after Heimlich maneuver. Patient survived.
(Bintz et al. 1996)
Bintz, M. and T. H. Cogbill (1996). "Gastric rupture after the Heimlich maneuver." J
Trauma 40(1): 159-160.
Abstract:Since 1975, the Heimlich maneuver has been widely applied to
relieve upper airway obstruction caused by aspirated material. Lifethreatening complications have been documented following this simple
procedure. We report two cases of gastric rupture after use of the Heimlich
maneuver. Both patients experienced pulmonary and abdominal
symptoms. The diagnosis was confirmed in each case by the
demonstration of free intraperitoneal air on an upright chest
roentgenogram. Full-thickness gastric rupture along the lesser curvature of
the stomach was repaired in both patients; one patient died. Abdominal
pain or persistent abdominal distention despite nasogastric suction after
the Heimlich maneuver should prompt evaluation for possible gastric
493711533
rupture.
Level 5 (unsatisfactory, two cases)
Opposes H2
Case report of 2 cases of gastric rupture after Heimlich manoeuver. One patient survived,
one died from sepsis.
{Boussuges, 1985 #12489}
Boussuges, S., P. Maitrerobert, et al. (1985). "[Use of the Heimlich Maneuver on children
in the Rhone-Alpes area]." Arch Fr Pediatr 42(8): 733-6.
Abstract: In 27 children suffering from a foreign body in the respiratory tract with asphyxia, the Heimlich
manoeuvre, previously described, was successful in saving life of this dramatic situation in all cases, without
respiratory complication. While this method is better known by members of first-aid associations than by
pediatricians, it may be successfully used in very young children and infants.
Level 5 (fair)
Supports H2
Retrospective case series of successful use of Heimlich maneuver in very young children
and infants.
(Brauner 1987)
Brauner, D. J. (1987). "The Heimlich maneuver: procedure of choice?" J Am Geriatr Soc
35(1): 78.
No abstract supplied
Level 5 (poor, single case report)
Supports H4
Conscious patient eating peanut butter sandwich - failure of Heimlich manoeuvre, success
with finger sweep which removed large clot of peanut butter
(Byers 1987)
Byers, R. K. (1987). "Alternative to Heimlich maneuver." N Engl J Med 317(13): 840-1.
No abstract supplied
Level 5 (poor, 4 anecdotal case reports)
Proposes placing patient head-down over chair or bed as alternative to back slaps or
Heimlich. Reports 4 anecdotal successes with technique.
(Chapman et al. 1983)
Chapman, J. H., F. J. Menapace, et al. (1983). "Ruptured aortic valve cusp: a
complication of the Heimlich maneuver." Ann Emerg Med 12(7): 446-8.
Abstract: A case of traumatic rupture of the aortic valve as a complication of the Heimlich
maneuver is presented. Conformation was made by comparative echocardiographic
studies available from three months before and immediately following the incident. The
patient refused surgical intervention and died one month later with severe congestive
heart failure despite vigorous medical therapy.
Level 5 (unsatisfactory – single case report)
Opposes H2
{Cooper, 1992 #12490}
Cooper, A. (1992). "Liver injuries in children: treatments tried, lessons learned." Semin
Pediatr Surg 1(2): 152-61.
Abstract: Liver injuries continue to present the pediatric trauma surgeon with a formidable
challenge. Most injuries are minor and are managed nonoperatively, but major injuries can
be life-threatening and require immediate operation. Diagnosis is made clinically and
confirmed by means by hepatic enzymes and computed tomography. The mortality
493711533
associated with serious liver injuries in children is about 10%, usually from associated
injuries, but exceeds 50% if major lacerations or juxtahepatic venous injuries are present.
Level 5 poor ( 5 cases)
Opposes H2
Life-threatening liver injuries with Heimlich maneuver.
(Cowan et al. 1987)
Cowan, M., J. Bardole, et al. (1987). "Perforated stomach following the Heimlich
maneuver." Am J Emerg Med 5(2): 121-122.
Abstract: The use of infradiaphragmatic abdominal pressure for relief of airway obstruction
caused by food was first described by Henry Heimlich in 1974. Since that time, several
complications have been reported. We report a case of gastric perforation occurring in a
choking victim following the application of the Heimlich maneuver.
Level 5 (unsatisfactory, single case report)
Opposes H2
(Craig 1980)
Craig, T. J. (1980). "Medication use and deaths attributed to asphyxia among psychiatric
patients." Am J Psychiatry 137(11): 1366-73.
Abstract: In a review of the charts of inpatients who died in 1969-1977 the author found 49
whose death could be attributed to asphyxia. Compared with a matched control group, 48
of the asphyxia patients represented three distinct pathologic categories: 1) older patients
with a history of serious physical illness whose deaths appeared unrelated to psychotropic
medication use (40%), 2) a group whose deaths were associated with seizures (31%),
raising questions about subtherapeutic anticonvulsant levels in association with the use of
psychotropic drugs, and 3) a group of patients who choked to death (29%). Choking has
been theoretically linked to a combination of dopamine blockade plus strong
anticholinergic effects leading to impairment of swallowing. The third category appears to
have been virtually eliminated by the use of a drug monitoring system and the Heimlich
maneuver.
Level 4 (poor, small case series, minimal results presented)
Supports H2
Anecdotal report of several victims saved by the Heimlich manoeuvre.
(Croom 1983)
Croom, D. W. (1983). "Rupture of stomach after attempted Heimlich maneuver." Jama
250(19): 2602-3.
No abstract supplied
Level 5 (unsatisfactory)
Opposes H2
Gastric rupture after Heimlich, patient died.
(Cumberbatch et al. 1996)
Cumberbatch, G. L. and M. Reichl (1996). "Oesophageal perforation: a rare complication
of minor blunt trauma." J Accid Emerg Med 13(4): 295-6.
Abstract: Oesophageal perforation following blunt trauma is rare and accounts for less
than 10% of all oesophageal ruptures. Review of published reports revealed only two
cases of isolated oesophageal perforation after minor blunt trauma, and these were as a
direct result of the Heimlich manoeuvre. This paper describes a case of perforation of the
oesophagus as an isolated injury following blunt minor trauma.
Level 5 (unsatisfactory, single case report)
Opposes H2
493711533
(Cunningham 2002)
Cunningham, A. (2002). "An audit of first aid qualifications and knowledge among team
officials in two English youth football leagues: A preliminary study." British Journal of
Sports Medicine 36(4): 295-300.
No abstract supplied
Level 7 (fair although only 34% response rate to questionnaire)
Survey of English sports coaches testing first aid knowledge(86 respondents). Survey
included questions on management of choking. Minimal data on results presented for
choking. Reports 72% qualified and 88% unqualified would treat choking victim
(conscious + coughing) incorrectly. 62% would do finger sweeps.
(Day et al. 1982)
Day, R. L., E. S. Crelin, et al. (1982). Choking: the Heimlich abdominal thrust vs back
blows: an approach to measurement of inertial and aerodynamic forces. 70: 113-119.
No abstract supplied
Level 6 (poor, no statistical analysis to allow comparison between techniques).
Opposes H1, supports H2
Accelerometer attached to two adult volunteers to determine direction of force with back
blows. Comparison of back blows and abdominal thrusts. Air pressure generated
compared in 4 adult volunteers using 3 different pressure methods.
Findings: Back blows caused upward acceleration of neck and upper back that would
theoretically propel a foreign body towards the glottis.
Back blows generated lower pressures (11.5 vs 21.25 mm Hg) of shorter duration (0.01
sec vs 0.7 sec) than abdominal thrusts.
(Dupre et al. 1993)
Dupre, M. W., E. Silva, et al. (1993). "Traumatic rupture of the stomach secondary to
Heimlich maneuver." Am J Emerg Med 11(6): 611-612.
Abstract: The case of a 93-year-old man who received a Heimlich maneuver while choking
is reported. After the procedure, the patient presented with abdominal pain and ultimately
was found to have developed a gastric rupture. He was hospitalized for 66 days. Review
of the literature showed that only four gastric perforations related to the Heimlich
maneuver have been documented. Other complications have occurred. It is reasonable to
perform the procedure as an alternative to asphyxiation, but emergency physicians must
be aware of the fact that life-threatening complications may ensue.
Level 5 (unsatisfactory, single report)
Opposes H2
(Elam et al. 1960)
Elam, J. O., D. G. Greene, et al. (1960). "Head-tilt method of oral resuscitation." JAMA
172: 812-815.
Abstract: Twenty-one successful users of oral resuscitation for victims of asphyxia were
questioned to evaluate the acceptability and effectiveness of the method and the details of
technique in the hands of laymen in the field. Vomiting and trismus, occurred in 1 and 13
cases, respectively, and three patients had convulsions. Pallor or cyanosis was uniformly
noted. Two patients, though successfully resuscitated temporarily, died subsequently.
The six rescuers who were unhappy about the experience in retrospect rescued victims
who either vomited or were drowning in sewage. Ten rescuers were not upset by the
experience in retrospect, even though their patients vomited. The thumb-in-the-mouth
technique, which had been extensively promoted in the area during the time of this survey,
was attempted in only a few instances and was discontinued because the thumb was
bitten in some cases
Level 7, fair (small numbers, biased as not truly evaluating finger sweep)
Supports H4
Thumb in mouth technique infrequently used and led to thumb being bitten in several
cases.
493711533
(Fearing et al. 2002)
Fearing, N. M. and P. B. Harrison (2002). "Complications of the heimlich maneuver: case
report and literature review." J Trauma 53(5): 978-9.
No abstract supplied
Level 5 (unsatisfactory – single case):
Opposes H2
Case report of single patient that died from aortic dissection after performing Heimlich
manoeuvre.
Ruptured stomach in patient administered Heimlich manoever in standing and supine
position. Patient survived.
(Feldman et al. 1986)
Feldman, T., S. M. Mallon, et al. (1986). "Fatal acute aortic regurgitation in a person
performing the Heimlich maneuver." N Engl J Med 315(25): 1613.
No abstract supplied
Level 5 (unsatisfactory – single case): Case report of single patient that died from aortic
dissection after performing Heimlich manoeuvre.
Opposes H2
(Fink et al. 1989)
Fink, J. A. and R. L. Klein (1989). "Complications of the Heimlich maneuver." J Pediatr
Surg 24(5): 486-487.
Abstract: This report describes a case of pneumomediastinum in a 3-year-old child
following the incorrect performance of the Heimlich maneuver.
Level 5 (unsatisfactory – single case)
Opposes H2
(Fioritti et al. 1997)
Fioritti, A., L. Giaccotto, et al. (1997). "Choking incidents among psychiatric patients:
retrospective analysis of thirty-one cases from the west Bologna psychiatric wards." Can J
Psychiatry 42(5): 515-520.
Abstract: OBJECTIVE: To determine the rate of choking incidents among the psychiatric
population of 4 inpatient facilities, classifying the incidents according to their probable
etiology. METHOD: All incidents recorded over 18 months were retrospectively analyzed
for demographic variables, psychiatric and medical diagnoses, and drug therapy at the
time of incident. Where possible, patients underwent psychiatric, neurological, and
medical examination. RESULTS: Thirty-one incidents were recorded involving 18 patients
at a rate of one incident every 56.32 months' hospitalization per person. One case proved
fatal, one patient died several weeks after the incident from aspiration pneumonia, and 5
patients needed reanimation or the Heimlich manoeuvre. Etiological classification showed
that incidents due to bradykinetic dysphagia and "fast eating" were the most
numerous, even among the fatal or grave cases. CONCLUSIONS: Various simple,
effective preventive measures emerge from the study.
Level 5 (unsatisfactory)
Supports H2
Anecdotal report of 4 successes with Heimlich manoeuvre
(Gallardo et al. 2003)
Gallardo, A., R. Rosado, et al. (2003). "Rupture of the lesser gastric curvature after a
Heimlich maneuver." Surg Endosc 17(9): 1495.
Abstract: BACKGROUND: We present a case of lesser gastric curvature injury after a
Heimlich maneuver due to obstruction of the breathing tract that was repaired by
laparoscopic surgery. METHODS: A patient with perforation of the lesser gastric curvature
as a result of closed abdominal traumatism was operated on using the laparoscopic
approach with the use of four trocars as work openings. With this technique, the diagnosis
493711533
was confirmed, the injury repaired, and the abdominal cavity washed. RESULTS: The
postoperative period was favorable and the patient was released from the hospital on day
7 without any complications. CONCLUSIONS: Laparoscopic surgery can be technically
reproduced in the treatment of gastric injury as a result of closed abdominal traumatism.
Level 5 (unsatisfactory – single case)
Opposes H2
(Guildner et al. 1976)
Guildner, C. W., D. Williams, et al. (1976). "Airway obstructed by foreign material: the
Heimlich maneuver." JACEP 5(9): 675-677.
Abstract: To investigate the application of a cough-creating thrust for the removal of
airway-obstructing foreign material, the thrust was applied to six adult male anesthetized
volunteers at the waist, at the low chest level, and at the midchest level, with the subjects
in both the horizontal-lateral and the sitting positions. Air volume, peak air flow rate, and
airway measurements were made. Both the low chest and midchest thrusts produced
significantly better results than did the abdominal thrust. There were no side effects
attributable to the thrusts. The ease of application and consistently better level of results
indicate that the chest thrust is the technique of choice. The application of the chest thrust
should be integrated into the concepts of basic life-support and cardiopulmonary
resuscitation.
Level 3 (poor – no statistical analysis)
Supports H3, opposes H2
Heimlich, low chest thrust(2 fingers above xiphoid) and mid chest thrust performed on 6
healthy anaesthetized, intubated adults in sitting and horizontal position by 4-5 volunteers.
Peak flow rate, volume and peak pressure were measured with each technique. No
statistical comparisons presented. Low chest thrust produced higher values for all
parameters than other techniques. Heimlich and mid chest thrust produced similar values.
All parameters appeared higher in sitting compared to horizontal position.
(Hartrey et al. 1995)
Hartrey, R. and R. M. Bingham (1995). "Pharyngeal trauma as a result of blind finger
sweeps in the choking child." J Accid Emerg Med 12(1): 52-54.
No abstract supplied
Level 7 (paediatrics, single case report)
Opposes H4
9 week old girl choked on tissue paper. Finger sweeps led to pharyngeal and tonsillar
laceration. Back slaps cleared obstruction.
(Haynes et al. 1984)
Haynes, D. E., B. E. Haynes, et al. (1984). "Esophageal rupture complicating Heimlich
maneuver." Am J Emerg Med 2(6): 507-9.
No abstract supplied
Level 5 (unsatisfactory – single case)
Opposes H2
(Heimlich et al. 1975)
Heimlich, H. J., K. A. Hoffmann, et al. (1975). "Food-choking and drowning deaths
prevented by external subdiaphragmatic compression. Physiological basis." Ann Thorac
Surg 20(2): 188-195.
No abstract supplied
This paper had two parts
Level 5 (fair) – supports H2
493711533
96 anecdotal reports of successful use reported (no details provided).
Level 3 (fair) supports H2
Experiment in conscious adult volunteers (n=10) looking at peak pressure, volume and
flow rate following the Heimlich maneuver during different phases of respiration.
Procedure during early expiration : Average flow 205 L/min, vol 940 ml, pressure
31mmHg; late respiration: 75L/min, 350ml
(Heimlich 1975)
Heimlich, H. J. (1975). "A life-saving maneuver to prevent food-choking." JAMA 234(4):
398-401.
No abstract supplied
Level 5 (poor, biased sample, cases inadequately described)
Supports H2
Review of early experiments in 4 Beagles which compared chest compression and
abdominal thrust for clearing an experimentally obstructed airway (bung in end of tracheal
tube or hamburger inserted into larynx). Reports failure of chest compression technique
but universal success with abdominal thrusts. No detailed methodology presented
Second part of paper reports 9 months experience of use abdominal thrust technique.
Reports were obtained by requesting feedback from healthcare professionals and the
public. 162 cases of successful use reported. In six cases, the technique was by self
administration by the choking victim.
These anecdotal reports indicate that there was no need to clear the mouth after
performing the technique as the object was expelled spontaneously in each case,
furthermore that the technique was successful in partial and complete airway obstruction.
2 victims suffered rib fractures “when technique was performed incorrectly”.
5 reports of success in drowning victims.
(Heimlich 1976)
Heimlich, H. J. (1976). "Death from food-choking prevented by a new life-saving
maneuver." Heart Lung 5(5): 755-8.
No abstract supplied
Level 5 (unsatisfactory)
Supports H2
Descriptive report of Heimlich manoeuvre. Includes statement that over 500 people have
been saved with manoeuvre – 50 of whom back slaps had failed to relieve obstruction.
(Heimlich 1982)
Heimlich, H. J. (1982). "First aid for choking children: back blows and chest thrusts cause
complications and death." Pediatrics 70(1): 120-5.
No abstract available
Level 7(unsatisfactory – few studies from peer reviewed journals)
Supports H2, opposes H1+3
Review of literature demonstrating dangers of back blows and chest thrusts and
advantages of Heimlich manoeuvre. Presentation of case reports where back slaps failed
or led to death.
Unable to get hold of most of the literature quoted for this review.
(Ingalls 1979)
Ingalls, T. H. (1979). "Heimlich versus a slap on the back." N Engl J Med 300(17): 990.
493711533
No abstract supplied
Level 5 (unsatisfactory)
Supports H1
Case report of successful back slap
(Kirshner et al. 1985)
Kirshner, R. L. and R. M. Green (1985). "Acute thrombosis of abdominal aortic aneurysm
subsequent to Heimlich maneuver: a case report." J Vasc Surg 2(4): 594-6.
Abstract: We report a case of acute thrombosis of an abdominal aortic aneurysm
secondary to a correctly applied and successful Heimlich maneuver. Although the
Heimlich maneuver is generally safe and effective, this possible catastrophic consequence
needs to be recognized.
Level 5 (unsatisfactory – single case)
Opposes H2
(Langhelle et al. 2000)
Langhelle, A., K. Sunde, et al. (2000). "Airway pressure with chest compressions versus
Heimlich manoeuvre in recently dead adults with complete airway obstruction."
Resuscitation 44(2): 105-108.
Abstract: In a previous case report a standard chest compression successfully removed a
foreign body from the airway after the Heimlich manoeuvre had failed. Based on this case,
standard chest compressions and Heimlich manoeuvres were performed by emergency
physicians on 12 unselected cadavers with a simulated complete airway obstruction in a
randomised crossover design. The mean peak airway pressure was significantly lower
with abdominal thrusts compared to chest compressions, 26.4+/-19.8 cmH(2)O versus
40.8+/-16.4 cmH(2)O, respectively (P=0.005, 95% confidence interval for the mean
difference 5.3-23.4 cmH(2)O). Standard chest compressions therefore have the potential
of being more effective than the Heimlich manoeuvre for the management of complete
airway obstruction by a foreign body in an unconscious patient. Removal of the Heimlich
manoeuvre from the resuscitation algorithm for unconscious patients with suspected
airway obstruction will also simplify training.
Level 2 (fair – small numbers)
Supports H3+5, opposes H2, extrapolated to support H6
Randomised cross over comparison of chest compressions and abdominal thrusts in
recently deceased adults (n=12) with simulated complete airway obstruction. Endpoint
was peak airway pressure. Findings – average peak airway pressure greater with chest
compressions than abdominal thrusts (40.8cmH2O versus 24.6, P=0.005).
Study also reports that abdominal thrusts did not work in thin subjects (n=2) and chest
thrust did not work as well as abdominal thrust in obese subject.
(Lapostolle et al. 2000)
Lapostolle, F., M. Desmaizieres, et al. (2000). "Telephone-assisted Heimlich maneuver."
Ann Emerg Med 36(2): 171.
No abstract supplied
Level 5 (unsatisfactory – single case report)
Supports H2
Emergency dispatcher instructed patient to self administer the Heimlich maneuver
successfully.
(Mack et al. 2002)
Mack, L., T. L. Forbes, et al. (2002). "Acute aortic thrombosis following incorrect
application of the Heimlich maneuver." Ann Vasc Surg 16(1): 130-3.
Abstract: The Heimlich maneuver has been widely accepted as a safe and effective
method of relieving life-threatening foreign-body upper airway obstruction. When applied
incorrectly, however, it may result in direct trauma to the intraabdominal viscera. Only two
cases of major aortic complications have been reported. Both have involved thrombosis of
493711533
an abdominal aortic aneurysm. We report two further instances of aortic thrombotic
complications due to the incorrect application of the Heimlich maneuver. The first case
resulted in thrombosis of an abdominal aortic aneurysm. In the second case the
abdominal thrusts caused dislodgement of thrombus from an atherosclerotic
nonaneurysmal aorta, which resulted in thromboembolic occlusion of both lower
extremities. In both cases, as with the two previously reported instances, massive
reperfusion injury resulted, which eventually proved fatal. When applied incorrectly, the
Heimlich maneuver may result in direct trauma to the abdominalaorta and is an unusual
cause of acute aortic thrombosis.
Level 5 (unsatisfactory – two cases)
Opposes H2
(Majumdar et al. 1998)
Majumdar, A. and P. C. Sedman (1998). "Gastric rupture secondary to successful
Heimlich manoeuvre." Postgrad Med J 74(876): 609-610.
Abstract: A fatal case of gastric rupture following the Heimlich manoeuvre is reported. This
life-threatening complication has only been reported previously in seven patients with a
high mortality rate. All patients should be assessed immediately following this manoeuvre
for any potentially life-threatening complications.
Level 5 (unsatisfactory, single case report)
Opposes H2
(Meredith et al. 1986)
Meredith, M. J. and R. Liebowitz (1986). "Rupture of the esophagus caused by the
Heimlich maneuver." Ann Emerg Med 15(1): 106-7.
No abstract supplied
Level 5 (unsatisfactory, single case report)
Opposes H2
(Nelson 1989)
Nelson, K. R. (1989). "Heimlich maneuver for esophageal obstruction." N Engl J Med
320(15): 1016.
No abstract supplied
Level 5 (unsatisfactory, single case report)
Supports H2
Case report of success of Heimlich manoeuvre in 8 year old child with esophageal
obstruction.
(Nowitz et al. 1998)
Nowitz, A., B. M. Lewer, et al. (1998). "An interesting complication of the Heimlich
manoeuvre." Resuscitation 39(1-2): 129-131.
Abstract:The removal of inhaled foreign bodies using the Heimlich manoeuvre is
recommended as part of the immediate management of the choking child. We report on a
case of witnessed laryngeal obstruction by a foreign body in which repeated Heimlich
manoeuvres failed to expel the foreign body, but temporarily relieved the obstruction. The
repeated Heimlich manoeuvres dislodged the foreign body into the trachea and may have
contributed to the rapid development of extensive surgical emphysema,
pneumomediastinum and pneumopericardium. The purpose of this report is to
demonstrate that the Heimlich manoeuvre was effective in relieving the airway obstruction,
but was associated with potentially severe complications.
Level 5 (unsatisfactory, single case)
Opposes H2
Case report of 7 year old boy choked on pen lid. Back slaps and turning upside down
ineffective. Heimlich tried 6 times before successful. Surgical emphysema,
pneumomediastinum and pneumopericardium developed immediately after Heimlich.
493711533
Patient survived.
(Olenchock et al. 2004)
Olenchock, S. A., Jr, D. M. Rowlands, et al. (2004). "Dysphagia After Heimlich Maneuver."
Chest 125(1): 302-304.
No abstract supplied
Level 5 (unsatisfactory, single case)
Opposes H2
Herniation of emphysematous bulla into the mediastinum 10 days after the patient self
administered the Heimlich manoeuvre.
{Orlowski, 1987 #741}
Orlowski, J. P. (1987). "Vomiting as a complication of the Heimlich maneuver." Jama
258(4): 512-3.
No abstract available
Level 5 (poor)
Opposes H2
5 case report of harm (potentially severe vomiting and aspiration) with Heimlich maneuver.
(Patterson et al. 1993)
Patterson, D. L., S. Brennan, et al. (1993). "Traumatic rupture of an aortic ulcerative
atherosclerotic plaque producing aortic dissection: a complication of interscapular back
blows used to dislodge objects from the esophagus." Clin Cardiol 16(10): 741-4.
Abstract: Penetrating atherosclerotic ulcer of the aorta is a rare entity which usually occurs
in the descending thoracic aorta. Herein, we report an unusual case of penetrating aortic
ulcer which ruptured into the mediastinum. Interscapular back blows were performed on
our patient in an attempt to dislodge an aspirin which she thought was lodged in her
esophagus. Unlike previously reported cases of this entity, the penetrating aortic ulcer in
our patient was located in the distal thoracic ascending aorta. Diagnosis of penetrating
aortic ulcer can be made by utilizing aortography, contiguous dynamic contrast-enhanced
computed tomography or magnetic resonance imaging. Treatment consists of adjunctive
medical therapy until surgery can be performed.
Level 5 (unsatisfactory, single case)
Opposes H2
{Penny, 1983 #12491}
Penny, R. W. (1983). "The Heimlich manoeuvre." Br Med J (Clin Res Ed) 286(6371):
1145-6.
No abstract supplied
Level of evidence 5 (unsatisfactory) single case report
Supports H2
Single case report of successful use of Heimlich by healthcare provider
(Razaboni et al. 1986)
Razaboni, R. M., C. E. Brathwaite, et al. (1986). "Ruptured jejunum following Heimlich
maneuver." J Emerg Med 4(2): 95-8.
Abstract: The Heimlich maneuver, over time, has proved to be a useful resuscitative
procedure in the management of cases with airway occlusion secondary to foreign body.
Medical treatments, however, can have side effects, and this maneuver is no exception. A
previously unreported complication is presented, that of jejunal rupture. The proper
application of the maneuver minimizes the number of side effects; however, since they do
occur, it is suggested that all persons subject to this maneuver be subsequently evaluated
by a physician as soon after the incident as is practicable.
493711533
Level 5 (unacceptable, single case)
Opposes H2
(Redding 1979)
Redding, J. S. (1979). "The choking controversy: critique of evidence on the Heimlich
maneuver." Crit Care Med 7(10): 475-479.
No abstract supplied
Level 5 (fair)
Supports H1-4
Review of studies and politics surrounding use of Heimlich manoeuvre
In addition review of 386 anecdotal reports of successes / failures of various choking
techniques voluntarily reported to the AHA registry. Interpretation of results difficult as
reports were anecdotal, data not systematically collected, probably favored successes
rather than failures, often reported by lay observers.
Review reports successes and failures for back blows, abdominal thrusts, chest thrusts,
finger probes, instrumentation and CPR used alone or in combination with each other.
(Rich 1980)
Rich, G. H. (1980). "Pneumomediastinum following the Heimlich maneuver." Ann Emerg
Med 9(5): 279-80.
No abstract supplied
Level 5 (unsatisfactory – single case)
Opposes H2
(Roehm et al. 1983)
Roehm, E. F., M. W. Twiest, et al. (1983). "Abdominal aortic thrombosis in association
with an attempted Heimlich maneuver." Jama 249(9): 1186-7.
Abstract: We report herein a case of an incorrectly applied Heimlich maneuver--to the best
of our knowledge, the first reported fatal complication associated with a Heimlich
maneuver, acute thrombosis of an abdominal aortic aneurysm, and the distal aorta. While
the Heimlich maneuver is effective for the relief of foreign body-induced upper airway
obstruction, increased efforts should be directed toward instructing the public in correctly
recognizing and optimally treating airway obstruction.
Level 5 (unacceptable, single case)
Opposes H2
(Ruben et al. 1961)
Ruben, H. M., J. O. Elam, et al. (1961). "Investigations of Pharyngeal Xrays and
Perfomance by Laymen." Anesthesiology 22(2): 271-9.
No abstract supplied
Level 7: fair
Supports H4
Review of evidence to date with inclusion of unpublished data and conjecture on best
practice from evidence available at the time.
Problems with procedures being too complex leading to failure in up to 1/3 of resuscitation
attempts. Particular problems with asphyxia leading to trismus and patients biting
rescuers thumb when placed on lower teeth.
(Ruben et al. 1978)
Ruben, H. and F. I. Macnaughton (1978). "The treatment of food-choking." Practitioner
221(1325): 725-9.
No abstract supplied.
Level 3 fair
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Supports H1+ H2
12 anaethetised, paralysed volunteers had Heimlich, sternal thrusts and back blows
performed on them. Intra-tracheal pressure and ability to dislodge various food
substances from model larynx also performed. Peak airway pressures were greatest for
back blows (median 25 cm H20), then sternal thrust (20 cm H20) then Heimlich (10 cm
H20). The duration of the pressure wave for each technique was 0.02 sec, 0.2 sec and
0.33 secs respectively. The area under the curve indicated that the Heimlich moved the
greatest volume of air. The model experiments were inconclusive. Conclude that back
slaps likely to be most effective.
(Sagar et al. 1989)
Sagar, P. and J. S. Goodman (1989). "Failure of Heimlich manoeuvre." Anaesthesia
44(8): 699-700.
No abstract supplied.
Level 5 (unsatisfactory)
Opposes H2
Single case report of failure of Heimlich technique to relieve FBAO in patient with matted
toilet paper in oropharynx. Obstruction ultimately removed by magills forceps.
{Skulberg, 1992 #746}
Skulberg, A. (1992). "Chest compression--an alternative to the Heimlich manoeuver?
[letter]." Resuscitation 24(1): 91.
No abstract supplied
Level 5 (unsatisfactory – single case report)
Opposes H2, supports H3
Singe case report of Heimlich maneuver failing to relieve airway obstruction in arrested
adult patient. Chest compressions were successful.
(Stix 2001)
Stix, M. S. (2001). "Knees-to-abdomen "Heimlich maneuver" in a morbidly obese patient."
Anesth Analg 92(6): 1619.
No abstract supplied
Level 5 (unsatisfactory – single case)
Supports H5
Noted during elective anaesthesia that lifting both legs up towards the abdomen in
morbidly obese patient caused anaethesia circuit to be ejected of tracheal tube, postulate
due to increased abdominal pressure being transmitted to thoracic cavity similar to
Heimlich manoeuvre.
(Tung et al. 2001)
Tung, P. H., S. Law, et al. (2001). "Gastric rupture after Heimlich maneuver and
cardiopulmonary resuscitation." Hepatogastroenterology 48(37): 109-111.
Abstract: Choking is a common emergency problem. The Heimlich maneuver is
unquestionably effective in relieving airway obstruction. Serious and life-threatening
complications may arise, however, if the maneuver is applied incorrectly. Two cases of
gastric rupture after Heimlich maneuver are reported. Lay public, paramedics and the
medical professionals should be educated with the correct technique of Heimlich
maneuver and its potential complications. All patients receiving Heimlich maneuver should
be examined by an experienced physician.
Level 5 (unacceptable, single case)
Opposes H2
(Ujjin et al. 1984)
Ujjin, V., S. Ratanasit, et al. (1984). "Diaphragmatic hernia as a complication of the
493711533
Heimlich maneuver." Int Surg 69(2): 175-6.
No abstract supplied
Level 5 (unsatisfactory, single report)
Opposes H2
(van der Ham et al. 1990)
van der Ham, A. C. and J. F. Lange (1990). "Traumatic rupture of the stomach after
Heimlich maneuver." J Emerg Med 8(6): 713-5.
Abstract: Fatal complications following the performance of the Heimlich maneuver have
been reported. A 76-year-old woman presented to the emergency department with signs
of respiratory distress, abdominal pain and distension one day after airway obstruction
and subsequent resuscitation. Despite successful immediate laparotomy and repair of a
ruptured stomach, she later succumbed to the sequelae of aspiration of gastric contents
and dehiscence of the gastric tear. This is the 4th case of stomach rupture and the 7th
reported fatal complication following the Heimlich maneuver. It is recommended that
persons who undergo the Heimlich maneuver be examined and observed by a physician,
as soon as possible, to rule out complications.
Level 5 (unsatisfactory, single report)
Opposes H2
Ruptured stomach after Heimlich, patient later died.
(Valero 1986)
Valero, V. (1986). "Mesenteric laceration complicating a Heimlich maneuver." Ann Emerg
Med 15(1): 105-6.
No abstract supplied
Level 5 (unsatisfactory, single case report)
Opposes H2
(Vilke et al. 2004)
Vilke, G. M., A. M. Smith, et al. (2004). "Airway obstruction in children aged less than 5
years: the prehospital experience." Prehosp Emerg Care 8(2): 196-9.
Abstract: BACKGROUND: Treatment of choking in children has been well studied, but few
data are available on the various causes of the choking episodes in the pediatric
population. OBJECTIVES: To assess frequency and to stratify etiologies of children less
than 5 years of age who had a 911 advanced life support (ALS) ambulance response for
airway obstruction. METHODS: A prehospital database was searched and information
was collected defining type of obstruction, age of the child, parents' action, paramedic
treatment, and incident outcome. RESULTS: There were 182 patients with airway
obstruction under 5 years of age, of whom 99 (55%) were less than 1 year old. Liquid
obstructions (i.e., formula, juices) were most common in the youngest children, whereas
solid food and nonfood solid obstructions were most prevalent in children over 1 year old.
One hundred seven (59%) of these obstructions resolved before paramedic arrival (69%
of liquid obstructions, 72% of food, and 36% of nonfood solid objects). Interventions used
by parents included bulb suction (3%), finger sweeps (6%), Heimlich maneuver (3%), and
back blows (12%). Paramedics used ALS skills in only three cases. After paramedic
evaluation, 47% of parents refused transport against medical advice (AMA).
CONCLUSIONS: Although most episodes of pediatric airway obstruction will have been
resolved by the time of paramedic arrival, age-specific and item-specific treatment skills
need to be reinforced with parents and prehospital providers.
Level 5 (fair – retrospective review of case notes, good numbers)
Supports H1,2,4
Database review of choking patients (age <5) that had received 911 emergency response.
182 cases, 99(55%) less than one year. 107(59%) resolved before paramedic arrived.
Methods used by parents – bulb suction (3%), finger sweeps (6%), Heimlich (3%), back
blows (12%). No breakdown on which techniques were successful.
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(Visintine et al. 1975)
Visintine, R. E. and C. H. Baick (1975). "Ruptured stomach after Heimlich maneuver."
JAMA 234(4): 415.
No abstract supplied
Level 5 (unsatisfactory, single case report)
Opposes H2
Heimlich manover performed (patient unconscious), meat expelled from mouth. Later
found to have ruptured stomach. Patient discharged alive.
(Westfal 1997)
Westfal, R. (1997). "Foreign body airway obstruction: when the Heimlich maneuver fails."
Am J Emerg Med 15(1): 103-5.
No abstract supplied
Level 5 (unsatisfactory, 2 case reports)
Opposes H2
Description of choking episodes where Heimlich maneuver failed and paramedics used
(Wolf 2001)
Wolf, D. A. (2001). "Heimlich trauma: a violent maneuver." Am J Forensic Med Pathol
22(1): 65-7.
Abstract: The Heimlich maneuver is a life-saving technique for dislodging foreign material
from the respiratory tract. This report illustrates intraabdominal injuries, including a large
mesenteric laceration, mesenteric contusions, and intraperitoneal hemorrhage, that
occurred in a recipient of a vigorously applied Heimlich maneuver. The potential for
confusing such injuries with homicidally inflicted injuries is emphasized.
Level 5 (unsatisfactory, single case report)
Opposes H2
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Excluded:
Assar, D., D. Chamberlain, et al. (2000). "Randomised controlled trials of staged teaching for basic life support, 1:
skill acquisition at bronze stage." Resuscitation 45(1): 7-15. Did not study choking
Associated Press (1999). Mom says 'thank you' to Heimlich: doctor's technique saved her son's life. Cincinnati Post.
Cincinnati, Ohio: http://www.cincypost.com/news/1999/heim071099.html. Not peer reviewed
Chen, C. H., C. L. Lai, et al. (1997). "Foreign body aspiration into the lower airway in Chinese adults." Chest 112(1):
129-133. Study of late presentation of fb obstruction.
Day, R. L. (1983). "Differing opinions on the emergency treatment of choking." Pediatrics 71(6): 976-978. No new
data, reanalyzed Redding Crit Care Med data.
Day, R. L. (1986). "Comments on first aid for victims of choking: an extension of remarks made upon receiving the
1986 Howland award. Acceptance of the Howland award 1986." Pediatr Res 20(10): 1013-1014.Opinion
Eigen, H. (1983). "Treatment of choking [letter]." Pediatrics 71(2): 300-301. Letter
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Ekberg, O. and M. Feinberg (1992). "Clinical and demographic data in 75 patients with near-fatal choking episodes."
Dysphagia 7(4): 205-208. Epidemiology paper, no treatment details provided.
Fioritti, A., L. Giaccotto, et al. (1997). "Choking incidents among psychiatric patients: retrospective analysis of thirtyone cases from the west Bologna psychiatric wards." Can J Psychiatry 42(5): 515-520. Epidemiological study looking
at factors contributing to choking in psychiatric patients
Fitzpatrick, P. C. and J. L. Guarisco (1998). "Pediatric airway foreign bodies." J La State Med Soc 150(4): 138-141.
Epidemiological study
Heimlich, H. J. (1978). "Heimlich defends his maneuver." N Engl J Med 299(25): 1415. Opinion, no new evidence
presented.
Heimlich, H. J. (1981). "The Heimlich maneuver: first treatment for drowning victims." Emerg Med Serv 10: 27-30.
Drowning, not choking
Heimlich, H. J. (1981). "Subdiaphragmatic pressure to expel water from the lungs of drowning persons." Ann Emerg
Med 10(9): 476-480. Drowning
Heimlich HJ "Back blows and choking." Pediatrics 71(6): 982-4.
Heimlich, H. J. (1993). "Cardiopulmonary resuscitation [letter]." JAMA 269(20): 2627. letter
Heimlich HJ (1981). "The Heimlich maneuver: first treatment for drowning victims." Emerg Med Serv 10: 27-30.
Drowning
Heimlich, H. J. and E. G. Spletzer (1993). "Drowning [letter]." N Engl J Med 329(1): 65. Letter
Heimlich, H. J. and E. G. Spletzer (2001). "Chest compressions yielded higher airway pressures than Heimlich
maneuvers when the airway was obstructed." Resuscitation 48(2): 185-7. Letter
Heimlich, H. J., M. H. Uhley, et al. (1979). "The Heimlich maneuver." Clin Symp 31(3): 1-32. Unable to get reference
Lan, R. S. (1994). "Non-asphyxiating tracheobronchial foreign bodies in adults." Eur Respir J 7(3): 510-514. Review
of late presentations of FBAO.
Lin, M. T., C. Y. Yeung, et al. (2003). "Management of foreign body ingestion in children: experience with 42 cases."
Acta Paediatr Taiwan 44(5): 269-73. Hospital treatment rather than emergency treatment for inhaled foreign bodies.
Moore, E. W. and M. W. Davies (1999). "A slap on the back." Anaesthesia 54(3): 308-309. Use of postcordial thump
for VT.
Modell, J. H. (1981). "Is the Heimlich maneuver appropriate as first treatment for drowning?" Emerg Med Serv 10(6366). Drowning
Montgomery, W. H. (1983). "Back blows and choking." Pediatrics 71(6): 982-4. Opinion
Orlowski, J. P. (1987). "Vomiting as a complication of the Heimlich maneuver." JAMA 258(4): 512-513.Heimlich
manoeuvre performed on drowning victim led to vomiting, aspiration, persistent vegetative state and subsequent
death 7 years later.
Patrick, E. (1981). "A case report: the Heimlich maneuver." Emergency 13: 45-47. Not medline reference, unable to
trace
Rimell, F. L., A. J. Thome, et al. (1995). "Characteristics of objects that cause choking in children." JAMA 274(22):
1763-1766. Epidemiological study of which objects children choke on.
493711533
Rosen, P., M. Stoto, et al. (1995). "The use of the Heimlich maneuver in near-drowning: Institute of Medicine report."
J Emerg Med 13(3): 397-405. Review – no new data
Sternbach, G. and R. T. Kiskaddon (1985). "Henry Heimlich: a life-saving maneuver for food choking." J Emerg Med
3(2): 143-148. Opinion / review; no new data. Suggests that back-blows (high pressure, short duration) may loosen
object from vocal cords whilst chest / abdominal thrusts may expel loosened object.