Addressing Recent Changes in AHA Guidelines on Choking in Adults and Children

It’s a beautiful summer day and you’re actually off duty on a Saturday. You’re meeting family and friends for a brunch with bottomless mimosas. You note, with some amusement, a couple on a date that doesn’t seem to be going well: the woman is openly scrolling her phone while the man slumps deeper and deeper into his chair, pretending to be entranced by the pastry menu.

Before you even manage to finish your first mimosa, you hear what experience has taught you is true screaming. The man you saw earlier is clawing at his throat and his eyes are enormous with terror. You tell the person sitting next to you to call 9-1-1 and walk quickly toward the table. You intercept him as he frantically stands and tries to stumble to the bathroom. You explain that you know what to do, and you’re going to help. He manages a desperate nod. He’s trying to speak and obviously can’t. He isn’t coughing at all.

What should you do now, according to the American Heart Association? The answer to that question has only recently changed.

The American Red Cross has been teaching people how to perform back blows on choking infants since 1933.¹ Furthermore, the Red Cross and the American Heart Association both taught back blows on choking victims of all ages until the mid-1980s. However, prior to 1974, adults and children with foreign bodies in their airways who didn’t respond to back blows either removed the obstruction on their own or died.² There was no meaningful escalation available at all. Magill forceps were invented in the 1920s, however weren’t commonly stocked in ambulances or used for emergent foreign body removal until decades later.³ As too many of us personally know, it’s rare for an ambulance to arrive and then remove the foreign body in time to prevent brain damage

Enter Dr. Henry Heimlich, for whom the famous maneuver is named.⁴ He ran a series of trials in 1974 on sedated beagles after reading an article about how many thousands of people die annually from choking. He found that a strong non-surgical force applied to the diaphragm through the abdomen could force out airway obstructions by forcing the residual volume in the lungs out with more force than anyone can exhale. He is credited with having saved untold thousands of lives with the development of this technique. He also, charmingly, reappeared in the news in 2016 at the age of 96 after successfully performing his maneuver on a choking woman in the dining room at his senior living community.⁴

However, it was at his bidding that back blows on any patient too large to be draped across a lap were removed from choking guidelines by both the Red Cross and the American Heart Association in 1986.¹ He referred to back blows as “death blows.” This recommendation would be reversed by the American Red Cross in 2006, whereby they would combine both traditional and newer techniques into a “5 and 5”: five back blows and then five abdominal thrusts.

In October 2025, nearly 20 years later, the American Heart Association release on choking adults and older children that would finally bring the two organizations back into agreement: back blows should be performed on all choking patients.⁵

The initial steps haven’t changed. If the patient is coughing strongly, encourage them to keep doing so, perform no procedure and monitor them for signs of worsening obstruction. However, if they have or develop signs of a serious airway obstruction, you need to act. These signs are intuitive but always worth repeating: A weak or absent cough, skin turning blue, an inability to speak or make noise at all, changes in mentation such as becoming lethargic, or someone who stops breathing entirely.

In these cases, begin with five back blows. The technique doesn’t differ significantly from that performed on infants: Slap the patient with the heel of your hand between their shoulder blades five times. Then perform five abdominal thrusts, standing behind the patient, wrapping your arms around them, and applying a hard force upward right below their ribcage. If the patient is too pregnant or obese for this to happen, perform five chest thrusts. This will involve the same sudden squeezing movement, just over their sternum instead of right below their ribcage. It’s a bit like chest compressions in CPR, just from behind and on someone who’s standing up.

These procedures may be uncomfortable for the patient or even injure them. Remember that clearing the object from the airway, at any cost, is the top priority. As always, make sure you’re up-to-date on the Good Samaritan laws in your state.

Continue this until the object is expelled, in which case you simply monitor the patient until EMS arrives. If you can’t expel the object with these steps, the patient will go down and become totally unresponsive. In that event, begin standard CPR, making sure to check the mouth for the obstruction before giving breaths. Also be sure to inform incoming ALS crews about the underlying cause of the arrest. ALS crews should, of course, prioritize removing the obstruction over any other procedure that would typically be performed first in a code, including shocks or epinephrine administration. No amount of defibrillation or medication is going to lead to a good neurologic outcome until the underlying cause of arrest is addressed. Do whatever needs to be done to return oxygen to the body.

As a reminder that cannot be repeated to ALS providers enough: As intimidating as cricothyrotomy can be, the most common error is failing to perform one in a timely manner when it’s obviously indicated.⁶

You explain briefly what you’re going to do. You stand behind the boy and firmly strike between his shoulder blades five times and then wrap your arms around his torso and perform five abdominal thrusts. You notice the skin of the back of his neck is turning blue, and he’s starting to sway on his feet. You return to the back blows. On the third one there’s a soft noise and then a louder one as he starts gasping and crying.

You face the boy now and look in his mouth: nothing can be seen. His skin pinks up immediately and he’s breathing in huge, gulping breaths. You walk over and pick up the offending object: a chunk of the triple-chocolate muffins this cafe is famous for. The boy turns more fully away from his date, clearly embarrassed to be crying.

He finds the breath to thank you.

“I’d be crying a lot more than that,” you assure him. “That was a close one.”

He doesn’t seem comforted. You wait with him until B Shift arrives to take over care and monitoring. The on-duty captain tells you, only mostly joking, that you won’t get any overtime for this.

You tell him you expected nothing less and return to your cocktails and waffles.

Works Cited:

1. Schlesinger, C. (2019a, May 20). Choking emergency: The Heimlich maneuver or back blows. In Home CPR. https://inhomecpr.com/choking-emergency-the-heimlich-maneuver-or-back-blows/.
2. The Man Behind the Maneuver. (2013). Radiolab. Retrieved 2025, from https://radiolab.org/podcast/273532-heimlich.
3. Coco Thomas, B., Michael Berkenbush, M., Raymond Dwyer III, B., Scott E Kansky, B., & Coco Thomas, B. (2022, June 2). Grabbing life by the handles: Optimal Utilization of Magill forceps. EMS Airway. https://emsairway.com/2022/05/31/grabbing-life-by-the-handles-optimal-utilization-of-magill-forceps/#gref.
4. Shortell, D. (2016, May 28). Henry Heimlich, 96, uses his maneuver to Save Woman. CNN. https://www.cnn.com/2016/05/27/us/heimlich-inventor-uses-maneuver.
5. Adult foreign-body airway obstruction verify scene safety. activate emergency. American Heart Association. (2025). https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Algorithms/Algorithm-BLS-Adult-FBAO-250630.pdf?sc_lang=en.
6. EMCrit 131 - Cricothyrotomy - Cut to Air: Emergency Surgical Airway. (2023). Youtube. Retrieved 2025.