Choking: Signs and First Aid

Signs of choking

Mild (partial) blockage

• The person can cough loudly, speak or cry, and breathe.
• Their face may be red and eyes watering.

What to do: encourage them to keep coughing. Coughing is more effective than any first aid at this stage. Stay with them and do not slap their back while they are coughing well.

Severe (complete) blockage

• Unable to speak, cry or breathe
• Weak, silent or no cough
• High-pitched noises or no sound when trying to breathe in
• Hands clutching the throat (the universal choking sign)
• Lips and skin turning blue or gray
• Panic, then loss of consciousness

Act immediately.

First aid for choking in adults and children over 1 year

1. Ask: "Are you choking?" If they nod and cannot speak, tell them you are going to help. Have someone call 911 or your local emergency number.
2. Back blows: stand slightly behind them, support their chest with one hand and lean them well forward. Give up to 5 firm blows between the shoulder blades with the heel of your other hand. Check after each blow whether the object has come out.
3. Abdominal thrusts (Heimlich maneuver): if back blows fail, stand behind them, wrap your arms around their waist, make a fist and place it just above the belly button, below the breastbone. Grasp your fist with your other hand and pull sharply inward and upward up to 5 times.
4. Repeat cycles of 5 back blows and 5 abdominal thrusts until the object comes out or they become unresponsive.

US guidance from the American Heart Association teaches abdominal thrusts alone, while the American Red Cross and UK and European guidelines combine back blows and abdominal thrusts. Both approaches are acceptable. Follow whichever you were trained in.

Special situations

• Pregnant or very large person: use chest thrusts instead of abdominal thrusts. Place your fist on the center of the breastbone and pull straight back.
• Small child: kneel or sit behind them so your hands are at the right height.
• If you are alone and choking: call 911 if you can, then thrust your fist above your belly button, or press your upper abdomen hard against the back of a chair or countertop.

First aid for a choking baby (under 1 year)

1. Back blows: lay the baby face down along your forearm, with the head lower than the chest, supporting the jaw with your hand. Rest your arm on your thigh. Give up to 5 firm back blows between the shoulder blades with the heel of your hand.
2. Chest thrusts: turn the baby face up along your other arm, head lower than the body. Place two fingers on the center of the chest just below the nipple line and give up to 5 sharp chest thrusts, pushing down about 4 cm (1.5 in).
3. Repeat until the object comes out or the baby becomes unresponsive.

Never give abdominal thrusts to a baby under 1, and do not try to sweep the mouth blindly with a finger, as this can push the object deeper. Remove an object only if you can clearly see it and easily grasp it.

If the person becomes unresponsive

1. Lower them carefully to the floor.
2. Call 911 or your local emergency number if not already done, and get an AED if one is nearby.
3. Start CPR with chest compressions. Chest compressions can help push the object out.
4. Each time you open the airway to give breaths, look in the mouth and remove the object only if you can see it.
5. Continue until help arrives or the person starts breathing normally.

After a choking episode

Get medical advice if:

• abdominal or chest thrusts were used, as they can injure internal organs
• a cough, wheeze, noisy breathing, chest pain or difficulty swallowing persists
• you are not sure the whole object came out

Persistent cough or wheeze after choking, especially in a toddler, can mean an object has moved into a smaller airway. This is foreign body aspiration and may need a bronchoscopy to remove it. Missed objects can cause pneumonia in that part of the lung.

Common causes of choking

• Adults: large pieces of meat eaten quickly ("café coronary"), talking or laughing while eating, alcohol, poorly fitting dentures, and swallowing problems after stroke or with dementia or Parkinson's disease.
• Young children: whole grapes, hot dogs, nuts, popcorn, hard candy, chunks of raw vegetables or apple, coins, small toy parts, balloons, magnets and button batteries.

Choking vs other breathing emergencies

Sudden throat tightness without eating, with hives, lip swelling or wheeze, is more likely anaphylaxis. Barking cough and noisy breathing in a child with a cold suggests croup. A swallowed button battery may not cause choking but is an emergency because it can burn the esophagus within 2 hours.

Repeated coughing or choking while eating

Frequent coughing on food or drink is a sign of aspiration and a swallowing disorder (dysphagia). A doctor can refer you to a speech-language pathologist for a swallowing assessment.

Preventing choking

For children

• Cut grapes, cherry tomatoes and hot dogs lengthwise into quarters, and cook or grate hard vegetables.
• Avoid whole nuts, popcorn and hard candy for children under 4 to 5.
• Seat children upright for meals and snacks, and supervise them. No eating while walking, playing or in a moving car.
• Keep coins, small batteries, magnets, balloons and small toy parts out of reach. Check toy age labels.

For adults

• Cut food into small pieces and chew thoroughly.
• Avoid talking or laughing with food in your mouth.
• Limit alcohol at meals.
• Make sure dentures fit well.
• Get a swallowing assessment if you cough or choke often.

Learn the skills

Take a first aid or CPR course. Infant and child first aid classes are especially valuable for parents and caregivers.

Frequently asked questions

What should you do first if someone is choking?

Ask if they are choking. If they can cough or speak, encourage them to keep coughing. If they cannot speak, cough or breathe, have someone call 911 and give up to 5 back blows followed by up to 5 abdominal thrusts, repeating until the object comes out.

How do you help a choking baby?

Lay the baby face down along your forearm with the head low and give up to 5 firm back blows. Then turn them face up and give up to 5 chest thrusts with two fingers in the center of the chest. Repeat. Never do abdominal thrusts on a baby.

Should I go to the doctor after choking?

Yes, if abdominal or chest thrusts were used, or if any cough, wheezing, chest pain, throat pain or difficulty swallowing continues. Thrusts can injure internal organs, and part of the object may still be in the airway or esophagus.

Can you choke on water?

Yes, water can go down the wrong way and cause coughing, but it rarely causes a complete blockage. The cough usually clears it. If someone cannot breathe or speak after inhaling liquid, treat it as choking. Frequent coughing on drinks suggests a swallowing problem.

What foods are choking hazards for young children?

The highest-risk foods are whole grapes, hot dogs, whole nuts, popcorn, hard and sticky candies, chunks of raw carrot or apple, cherry tomatoes, marshmallows and spoonfuls of peanut butter. Cut round foods lengthwise into small pieces and supervise children while they eat.