Silent Choking at the Next Table in a Restaurant
You are having dinner in a restaurant when a 58-year-old man at the next table suddenly stops talking mid-sentence, puts both hands to his throat and stands up. He was eating steak. Over about 30 seconds his coughing weakens, the high-pitched noises between coughs stop, and he becomes silent and panicked. His face is reddening. He is conscious, still on his feet, but making no sound and not moving air. He is overweight with a large abdomen. Staff are shouting; one of them is about to slap him on the back while he is still standing upright. Another diner is already dialling on a mobile phone but has not spoken yet. You identify yourself as a first aider and take charge. He is significantly taller and heavier than you.
1. How do you assess whether he is choking effectively, and what do you do in the first 30 seconds?
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The key sign is the change from noisy coughing to silence. An effective cough means air is still moving, and the correct action then is to encourage coughing and do nothing else. An ineffective cough - silent, unable to speak or breathe, panicked, clutching the throat - means complete obstruction, and you must intervene immediately.
He is now silent and cyanosing, so start back blows. Stop the staff member: an untrained slap from the wrong position, on a standing casualty who is not leaning forward, is unlikely to help and may worsen the situation. Take charge clearly, ask him 'are you choking?' (he cannot answer), and tell him you are going to help.
Confirm that the diner on the phone is calling 112 and ask them to stay on the line. Do not wait to see whether the obstruction clears on its own before summoning help.
2. Describe the sequence of manoeuvres, including any modification for his body shape.
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Lean him forward and give 5 sharp back blows with the heel of your hand between the shoulder blades. After each set of 5, check whether the object has cleared. If not, give 5 abdominal thrusts: stand behind him, put a fist just above the umbilicus but well below the xiphisternum, grasp it with the other hand, and pull sharply inwards and upwards. Alternate 5 back blows and 5 abdominal thrusts, checking between sets.
He is obese with a large abdomen, and you are smaller than him, so an effective abdominal grip may be impossible. In that case, or if he were pregnant, use chest thrusts instead: hands on the lower half of the sternum, pulling sharply backwards. The aim is to generate a sudden rise in intrathoracic pressure.
Anyone who has received abdominal thrusts must be medically assessed afterwards, even if the object clears, because of the risk of internal injury.
3. He suddenly goes limp and starts to slide to the floor. What now, and what do you hand over?
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Lower him to the floor safely - protect his head, and do not let him fall onto furniture. Confirm 112 has been called. Start CPR immediately: chest compressions generate sufficient pressure to dislodge a foreign body in many cases. Each time you open the airway for a ventilation, look inside the mouth and remove only an object you can clearly see. Never perform a blind finger sweep, as it can push the object deeper.
Continue CPR, swapping compressors if anyone trained is available, until the ambulance crew takes over. If he starts breathing before they arrive, place him in the recovery position and monitor continuously.
Hand over: the time choking began, the manoeuvres used and how many sets, any change in consciousness, and the time CPR started. If the object clears and he recovers, he still needs hospital assessment after abdominal or chest thrusts.