BLS - FOREIGN BODY
-the choking child

• Visible foreign body in mouth
• Gagging
• Stridor
• Coughing (effective or ineffective coughing).

• Dyspnoea
• Cyanosis
• Apnoea if foreign body has occluded the airway enough to stop the patient from breathing entirely

• Tachycardia
• Absent pulse (if foreign body has obstructed airway leading to cardiorespiratory arrest)

• Unconscious
• Agitated due to hypoxia

• Assess for any other features which may suggest other causes of airway obstruction (e.g. temperature (in croup, epiglottitis etc), drooling (suggesting inability to swallow saliva, in epiglotitis )or urticaria/angioedema (e.g. anaphylaxis).
• In such cases attempts to relieve the obstruction using the methods described below are dangerous. The treatments of these specific conditions are dealt with elsewhere.

Response

Figure: Choking algorithm

Airway

• Don’t forget to shout for help.

• Does the child have an effective cough?
  • If the child is unconscious then by definition their cough is ineffective. Place the child on a flat surface. Open airway with a head tilt / chin lift manoeuvre and begin basic life support. If the foreign body is easily visible and accessible then remove it. Do not perform blind finger sweeps as this may push the foreign body further into the airway. 
  
  
  • If the child is conscious but their cough is ineffective and the foreign body is easily visible and accessible then remove it. Again, do not perform blind finger sweeps as this may worsen the obstruction.
  
  
  • If patient has an effective cough → continue to encourage coughing. A spontaneous cough is more effective at relieving an obstruction than any externally imposed manoeuvre. No other intervention is needed unless the cough becomes ineffective

Breathing

• If the patient is unconscious open the airway and give 5 rescue breaths. If a breath does not make the chest rise, reposition the head before making the next attempt.

• If the patient is conscious but has an ineffective cough give 5 back blows. Between each back blow check to see if the foreign body has been removed. The aim is to relieve the obstruction with each blow rather than to give all 5.  After the delivery of the 5 back blows or the 5 abdominal thrusts the child should be reassessed. 

• If the patient has an effective cough → continue to encourage coughing. Monitor for any deterioration to an ineffective cough

Figure: Back blows in infants: Support the infant in head downward, prone position, over your forearm. Keep the infant’s jaw open in neutral position. Make sure you do not compress the soft tissues around the jaw/neck as this will exacerbate the airway obstruction.

Figure: Back blows in children over 1 year: These are more effective if the child is positioned head down. A small child can be placed across the rescuer’s lap as shown. Larger children can be held in a forward-learning position with back blows delivered from behind.

• If back blows fail to dislodge the foreign body and the child is still conscious, perform 5 chest thrusts in infants or 5 abdominal thrusts in older children (see below). Abdominal thrusts may cause intra-abdominal injury in infants and are therefore not recommended.

Figure: Chest thrusts in infants

The infant is laid along the rescuers thigh, in the head-down position. Five chest thrusts are given using the same landmarks as for cardiac compression (lower sternum, approximately a finger’s breadth above the xiphisternum). These are sharper and delivered at a slower rate than chest compressions (one per second).

Figure: Abdominal thrusts in the older child

In older children, abdominal thrusts can be performed. The rescuer will move behind the child, passing their arms around the child’s body. One hand is formed into a fist and placed against the child’s abdomen, above the umbilicus and below the xiphisternum. The other is placed over the first, and both hands are thrust sharply upwards into the abdomen.

Following the chest or abdominal thrusts – reassess the child.

If the foreign body has not been expelled and the child remains conscious then continue the sequence of 5 back blows followed by 5 chest/abdominal thrusts. Call for help.

Circulation

Continue as above if the obstruction has not been removed and the patient remains conscious. A and B are your primary problems here so there is nothing you can do for circulation at this stage.

• If the patient is unconscious and your five rescue breaths have not helped bring back any signs of life, start chest compressions (rate of 15 chest compressions: 2 breaths). If it appears the object has been relieved – reassess again, starting from A.

Disability

• Assess conscious level
• If any deterioration in consciousness open the airway and start CPR.

Exposure

• Again, A and B are you primary problems here. However, if you note something on the rest of the examination (fever / rash) that suggests that choking may not be the cause of the presentation, you will need to rethink your management plan and treat accordingly.

If the child improves and retains consciousness and exhibits spontaneous breathing, place in the recovery position whilst monitoring breathing and conscious level whilst awaiting further help.