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493711533 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 493711533 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 493711533 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 493711533 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 493711533 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) 493711533 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 493711533 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 493711533 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 493711533 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 – 493711533 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. 493711533 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 493711533 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. 493711533 (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 *Type the citation marker in the first field and then paste the full citation into the second field. You can copy the full citation from EndNote by selecting the citation, then copying the FORMATTED citation using the short cut, Ctrl-K. After you copy the citation, go back to this document and position the cursor in the field, then paste the citation into the document (use Ctrl-V). For each new citation press Tab to move down to start a new field. 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 493711533 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.